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APPLICATION FOR ENCROACHMENT PERMIT< <br /> PLEASE PRINT: <br /> 2i S_P ?3 !(� 4 <br /> Date OFFICE OSE ONLY <br /> To: San Joaquin County JOB# 3 REF# <br /> Department of Public Works APN CR# <br /> Taber Consultants EXP. DATE <br /> (Applicant Name) STREET DRIVEWAYS: <br /> et <br /> AREA <br /> 3911 QUAD JUS- <br /> 3911 West Capitol Ave. TYPE C��S�Z' <br /> (Mailing Address) FORMS S�i,�,?� * <br /> NOTES ` <br /> West Sacramento,CA 95691 <br /> (City, State,Zip Code) <br /> (916)371.1690 <br /> (Area Code-Telephone Number) <br /> Sketch (Detailed plans may be submitted) <br /> SEE ATTACHED VICINITY & SITE MAP <br /> The undersigned hereby applies for permission to excavate, construct and/or otherwise encroach on County Highway Right-of-Way on <br /> the North side of Bollea Road <br /> of approximately feet/mile <br /> , by performing the following work(description of work): <br /> Two vertical borings for geologic investigation,on the northern side of Bollea Road.One boring in the roadway,the other on the shoulder.Borings will be backfilled <br /> with grout,and the roadway patched with dyed black concrete.Please see attached for traffic control. <br /> Work will commence on or about 10/12!2015 <br /> for approximately 2 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 /> Signature of Applicant-Title YX <br /> Date <br /> E:IPUS-S✓WKIMASTER.PSIENCROACHMENT PERMIT APPLICATION DOC (OM8) <br />