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APPLICATION FOR ENCROACHMENT PERMIT <br /> PLEASE PRINT: <br /> Date OFFICE USE ONLY <br /> To: San Joaquin County JOB# REF# <br /> Department of Public Works APN CR# <br /> EXP.DATE <br /> FRED BROWN VALID -2 -ZCJjS TO DRIVEWAYS: <br /> (Applicant Name) STREET ES cq I o� �Pt(�� ,q <br /> �( AREA QUAD _ <br /> C�;0 Li TYPE <br /> (Mailing Address) FORMS j3iAliAl R G <br /> NOTES <br /> W -"SGG . i C,A �j <br /> (City,State,Zip Code) <br /> (925) 327-0990 <br /> (Area Code-Telephone Number) <br /> Sketch(Detailed plans may be submitted) <br /> SEE ATTACHED SKETCH <br /> The undersigned hereby applies for permission to excavate,construct and/or otherwise encroach on County Highway Right-of-Way on <br /> the WEST side of 4377 S.ESCALON BELLOTA RD. approximately 500' feet/mile <br /> NORTH <br /> of HIGHWAY#4 by performing the following work(description of work): <br /> REPLACE A ROTTEN 45'POLE <br /> Work will commence on or about 10-23-2015 for approximately ONE days. <br /> I,the undersigned,certify that I am the owner of the respective property,or am qualified to represent the owner and agree to do the <br /> work described above in accordance with the rules and regulations of San Joaquin County and subject to inspection and approval. <br /> -fle ( rYOwil 4/21/2015 <br /> Signature of Applicant-Title Date <br /> M:ICENTRALSERVICESkCLERICALIPUBSV.WKWIASTER.PSIENCROACHMENT PERMIT APPLICATION DOC (09113) <br />