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APPLICATION FOR ENCROACHMENT PERMIT <br /> PLEASE PRINT: <br /> Date (pill OFFICE USE ONLY <br /> To: San Joaquin County JOB# 7300 SZ REF# <br /> Department of Public Works APN CR# <br /> EXP. DATE 7--IT k57 <br /> Nhan Ly VALID 8-6-15 TO DRIVEWAYS: <br /> (Applicant Name) STREET —A�A��iki <br /> AREA S QUAD <br /> 850 Stillwater ^ TYPE �yNC <br /> (Mailing Address) FORMS Sf— 22 <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 /> Construction drawing is appended. Please refer to attachment. <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 S. Austin Rd. approximately 200' feet/mile South <br /> of Lynch Rd. , , by performing the following work(description of work): <br /> Replacement of deteriorated electric(facility)wood pole <br /> Work will commence on or about 7-10-2015 for approximately 30 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 /> 42p - Estimating Engineer 04-08-2015 <br /> Signature of Applicant-Title Date <br /> M:ICENTRALSERNCESICLERICALIPUESVAKIMASTER.PSIENCROACHMENT PERMIT APPLICATIONDOC (09173) <br />