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APPLICATION FOR ENCROACHMENT PERMIT <br /> PLEASE PRINT: <br /> Date 7/15/2015 OFFICE USE ONLY <br /> To: San Joaquin County JOB# REF# <br /> Department of Public Works APN VCR# <br /> ��/� s EXP.DATE �1 <br /> SON B(Applicant Name 6`1 (� STREET VALID TO / 3 J �� DRIVEWAYS: <br /> 1 <br /> (Applicant Name) - d <br /> AREA S QUAD _ <br /> 850 STILLWATER DR. ,TYPE <br /> (Mailing Address) FORMS <br /> WEST SACRAMENTO,CA,95605 NOTES <br /> (City,State,Zip Code) <br /> 925-327-0999 <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 side of approximately feet/mile <br /> of , <br /> REPLACE DETERIORATED POLE/PM 31119123 by performing the following work(description of work): <br /> 795 MANILA RD. <br /> Work will commence on or about for approximately 1-5 da s. <br /> 1� to Z3 1� Y <br /> I,the undersigned,certify that I am�he dler of�he 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 /> - V 7/15/2015 <br /> Signatu of Appl' nt-Title Date <br /> M.ICENTRALSERVICES,CLERICALIPUB-SV.WKIMASTER.PSIENCROACHMENTPERMITAPPLICATION.DOC (49113) <br />