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r <br /> APPLICATION FOR ENCROACHMENT PERMIT <br /> PLEASE PRINT: P <br /> Date _ OFFICE USE ONLY <br /> To: San Joaquin County JOB# '� Si—t ' REF# <br /> Department of Public Works APN CR# <br /> EXP.DATE <br /> DAVID SAVIT � �/ � <br /> VALID to G 15- TO ,Z t j�,, DRIVEWAYS: <br /> (Applicant Name) STREET O y /I <br /> AREA STdck-ro N QUAD <br /> 850 STILLWATER RD. TYPE <br /> (Mailing Address) FORMSvt,✓ <br /> W. SACRAMENTO, CA NOTES <br /> (City,State,Zip Code) <br /> 925--242-0446 <br /> (Area Code-Telephone Number) <br /> Sketch (Detailed plans may be submitted) <br /> The undersigned hereby applies for permission to excavate,construct and/or otherwise encroach on County Highway Right-of-Way on <br /> the WEST side of MOBLEY RD. approximately .9 MI feetlmile NORTH <br /> of GAWNE RD. by performing the following work(description of work): <br /> REPLACE DETERIORATED POLE <br /> Work will commence on or about 10/10/2015 — 1 110 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 /> DAVID SAVITZ 8/13/2015 <br /> Signature of Applicant-Title Date <br /> M:,CENTRALSERVICES•CLERICAL{PUB-SV,4VK.UASTER.PSIENCROACHME:NT PERMT APPLICATIONDoc (0 213) <br />