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APPLICATION FOR ENCROACHMENT PERMIT <br /> PLEASE PRINT: <br /> Date 5/14/2015 OFFICE USE ONLY <br /> To: San Joaquin County JOB# '716651, Q, REF# <br /> Department of Public Works APN CR# <br /> EXP.DATE <br /> Eugeno Ponce � ;tr VALID 10 f tj TO t t rS DRIVEWAYS: <br /> (Applicant Name) STREET t 160 rrk R�Pn:J tea, <br /> AREA <br /> 850 Stillwater Drive QUAD E <br /> TYPE ^(�„ e. t�U6ce <br /> (Mailing Address) FORMS <br /> NOTES <br /> West Sacramento, CA, 95605 <br /> (City,State,Zip Code) <br /> 925-327-0330 <br /> (Area Code-Telephone Number) <br /> Sketch (Detailed plans may be submitted) <br /> 1t )41 <br /> The undersigned hereby applies for permission to excavate, construct and/or otherwise encroach on County Highway Right-of-Way on <br /> the -k-f-t-Ai-tr side ofMB 16300 N.Ripon RD. 1PS approximately 580 Feet feet/mile 5Oa7W <br /> of French Camp RD by performing the following work(description of work): <br /> REPLACE DETERIORATED POLE. PM 31119017 . Traffic Control Plan will <br /> _be implemented in this project <br /> Work will commence on or about 7/01/2015 for approximately 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 /> � �y tbT-ct 5/14/2015 <br /> Si4dature of Applicant-Title Date <br /> M;(CENTRA.LSERVICESICLERICAL`PUBSV.WIC,hASTER.PSENCROACHMENTPERMff APPLICATION.DCC (09;13) <br />