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T <br /> PM#31139012-NOTIF: 110016111 <br /> APPLICATION FOR ENCROACHMENT PERMIT <br /> 9 <br /> 42 <br /> PLEASE PRINT: <br /> Date C2 (�S OFFICE USE ONLY <br /> To: San Joaquin County JOB# -7300 2.-113 REF# <br /> Department of Public Works APN CR# <br /> EXP.DATE 'z <br /> PGE VALID 14 i t y TO zJ21t(v DRIVEWAYS: <br /> (Applicant Name) STREET _MA;'A S+ <br /> AREA QUAD -6S <br /> 850 STILL WATER TYPE <br /> (Mailing Address) FORMS <br /> NOTES <br /> WEST SACRAMENTO,CA <br /> (City,State,Zip Code) <br /> 916-781-3145 <br /> (Area Code-Telephone Number) <br /> Sketch (Detailed plans may be submitted) <br /> REPLACE DETERIORATED POLE <br /> The undersigned hereby applies for permission to excavate,construct and/or otherwise encroach on County Highway Right-of-Way on <br /> the 5.grN —side of approximately 1 01 ' feet/mile 154S—) <br /> of --T>C-t YAOIC &40, by performing the following work(description of work): <br /> 11P/S 1/RW E.MAIN ST.,STOCKTON,CA 95215 <br /> Work will commence on or about Z 1-1V for approximately days. <br /> 1,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 /> RANDALL HATA 7/06/15 <br /> Signature of Applicant-Title Date <br /> fA:ICENTRA,LSERIACEStCLERfCALIPUB-SV.',VM,&tASTERPSENCRC)ACHNIENTPERMFrAPPLICATIQNDDC (09"13) <br />