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PM#31147604 NOTIF: 110141776 <br /> APPLICATION FOR ENCROACHMENT PERMIT / <br /> PLEASE PRINT: w <br /> Date OFFICE USE ONLY <br /> To: San Joaquin County JOB# "CD REF# <br /> Department of Public Works APN CR# <br /> ` EXP.DATE / ILo <br /> RANDALL RATA ,V y VALID ( I to 0 1 f1, DRIVEWAYS: <br /> (Applicant Name) ! STREET <br /> AREA A.P a:ok QUAD A <br /> 850 STILLWATER DR. TYPE (f 4 C[ <br /> (Mailing Address) FORMS L✓vo <br /> NOTES <br /> WEST SACRAMENTO,CA 95691 <br /> (City, State,Zip Code) <br /> (Area Code-Telephone Number) <br /> Sketch(Detailed plans may be submitted) <br /> The undersigned hereby applies for ermission to excavate,construct and/or otherwise encroach on County Highway Right-of-Way on <br /> the )�745r side of rJ ''.A• approximately A feeVI <br /> of A) RA6- I , by performing the following work(desc ption of work): <br /> REPLACE DETERIORATED POLE <br /> Work will commence on or about c>' 1, 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 /> 1V,\AN,DALL WA 07129/15 <br /> Signature of Applicant-Title Date <br /> MACENTRALSERIACESICLERICAL'PUSSV.'NK%IASTER.PSENCROACHIAENT PERM?APPLICATION.DOC (09;13) <br />