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APPLICATION FOR ENCROACHMENT PERMIT <br /> 25 Sir <br /> PLEASE PRINT: tt ``_ <br /> Date OFFICE USE ONLY <br /> To: San Joaquin County JOB# —/ REF# <br /> Department of Public Works APN CR# <br /> EXP.DATE 6l �t$ <br /> PG&E VALID r ' TO !/ / DRIVEWAYS: <br /> (Applicant Name) STREET Mot/910API <br /> 4040 WEST LN AREA 5'7'Ckrm/ QUAD <br /> TYPE SLG 1.1 <br /> (Mailing Address) FORMS <br /> STOCKTON, CA 95204 NOTES <br /> (City,State,Zip Code) <br /> 209-942-1599 <br /> (Area Code-Telephone Number) <br /> Sketch(Detailed plans may be submitted) <br /> PM# 31173650 <br /> NOTIF: 110451170 <br /> SEE ATTACHED SKETCH <br /> The undersigned hereby applies for permission to excavate,construct and/or otherwise encroach on County Highway Right-of-Way on <br /> the SOUTH side of WAUDMAN AVE approximately 305' feet/mile E <br /> of AGATEGT' STOCKTON by performing the following work(description of work): <br /> EXCAVATION OF(1) BELL HOLE IN ASPHALT . LJA <br /> Work will commence on or about 08/10/15 for approximately 90 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 /> a�/�./l S' <br /> // Signature of Applicant-Title Date <br /> E1PUMV.WKIMASTER.PSIENCROACHMENT PERMIT APPLICATION DOC (01108) <br />