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APPLICATION FOR ENCROACHMENT PERMIT <br /> PLEASE PRINT: <br /> Date 6/8/2015 OFFICE USE ONLY <br /> To: San Joaquin County JOB# 7 (,a sZ REF# <br /> Department of Public Works APN CR# <br /> EXP.DATE <br /> David Savitz VALID _6 -1,5 TO Q-(- s DRIVEWAYS: <br /> (Applicant Name) STREET as ll <br /> AREA ro6� QUAD <br /> 850 Stillwater Road TYPE <br /> (Mailing Address) FORMS 55 t4le <br /> NOTES <br /> West Sacramento, CA, 95605 <br /> (City,State,Zip Code) <br /> (925)327- (0990) <br /> (Area Code-Telephone Number) <br /> Sketch(Detailed plans may be submitted) <br /> The undersigned hereby applies for permission to excavate,construct and/or otherwise encroach on County Highway Right-of-Way on <br /> the East side of Wagner Road approximately 820 ft. <br /> PP Y feet/mile south <br /> of Yosemite Ave. by performing the following work(description of work): <br /> Replace deteriorated pole. <br /> Work will commence on or about 7/10/2015 for approximately 42 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 /> David Savitz 6/8/2015 <br /> Signature of Applicant-Title Date <br /> M:ICENTRALSERVICESCLERICALIPUR-SY.WKWASTER.PSiENCROACHMENT PERMIT APPLICATIONDOC (09113) <br />