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APPLICATION FOR ENCROACHMENT PERMIT <br /> PLEASE PRINT: <br /> Date 7/7/2015 OFFICE USE ONLY <br /> To: San Joaquin County JOB# 7�oa 5Z REF# <br /> Department of Public Works APN CR# <br /> JX <br /> / � - EXP.DATE-�CJfDAVID SAVITZ VALID ' - TO DRIVEWAYS: <br /> (Applicant Name) STREET fs IIA /9 p I 1, _ <br /> AREA QUAD _ <br /> 850 STILLWATER ROAD TYPE <br /> (Mailing Address) FORMS <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 /> TO (S"Ofir') <br /> 9U <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 ESCALON BELLOTA RD. approximately 1.6 mi feet/mile SOUTH <br /> of HIGHWAY 4 ,by performing the following work(description of work): <br /> REPLACE DETERIORATED POLE <br /> Work will commence on or about 10/13/2015 for approximately 105 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 7/7/2015 <br /> Signature of Applicant-Title Date <br /> M:tCENTRALSERVICES',CLERICAL,PUB-SV.WK'MASTER.PSIENCROACHMENTPERMRAPPLICATION.DOC (09113) <br />