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APPLICATION FOR ENCROACHMENT PERMIT <br /> PLEASE PRINT: gl&12-ot �- <br /> Date 1+1212e t!r OFFICE USE ONLY <br /> To: San Joaquin County JOB# 73 60 S REF# <br /> Department of Public Works APN CR# <br /> PG&E EXP.DATE 6-1 -15 <br /> VALID _S-1-l5 TO DRIVEWAYS: <br /> (Applicant Name) STREET AC 5-t <br /> 4040 WEST LN AREA Th og�,YAA QUAD IC_ <br /> TYPE T',�gy�CG1 <br /> (Mailing Address) FORMS <br /> STOCKTON, CA 95204 NOTES <br /> (City,State,Zip Code) <br /> 408-316-1767 <br /> (Area Code-Telephone Number) <br /> Sketch(Detailed plans may be submitted) <br /> SEE ATTACHED SKETCH <br /> 31084262 <br /> The undersigned hereby applies for permission to excavate,construct and/or otherwise encroach on County Highway Right-of-Way on <br /> the South side of W Oak St approximately at feet/mile <br /> of Alice Ave Thornton by performing the following work(description of work): <br /> Excavate (1)4'x4' bellhole (1)8"diameter well &trench 7' <br /> Work will commence on or abgut 5/1/2015 for approximately 30 days. <br /> I,the undersigne e0y I am the owner of the respective property,or am qualified to represent the owner and agree to do the <br /> work describe bov . accordance with the rules and regulations of San Joaquin County and subject to inspection and approval. <br /> V 41201 r <br /> Signa icant-Title Date <br /> EVU&SV. MENCROACHMENl PERMIT APPLICATION.DOC (t,I-) <br />