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PM#31139067 NOTIF:110016077 <br /> APPLICATION FOR ENCROACHMENT PERMIT <br /> PLEASE PRINT: <br /> Date q Ing 115 OFFICE USE ONLY <br /> To: San Joaquin County JOB# &2, — *EF# <br /> Department of Public Works APN CR# <br /> EXP.DATE 2 A —��6- <br /> PGE <br /> PGE VALID j(7.- ATO — a ' DRIVEWAYS: <br /> (Applicant Name) STREET <br /> AREA r 44-- UAD * <br /> 850 STILLWATER TYPE <br /> (Mailing Address) FORMS (N G <br /> �,�r <br /> WEST SACRAMENTO,CA (3 NOTES ! <br /> (City,State,Zip Code) t <br /> " <br /> (Area Code-Telephone Number) <br /> Sketch(Detailed plans may be submitted) <br /> CONSTRUCTION DRAWING AND PERMIT SKETCH ATTACHED. <br /> The undersigned hereby applies for permission to excavate,construct and/or otherwise encroach on County Highway Right-of-Way on <br /> the side of approximately feet/mile <br /> of by performing the following work(description of work): <br /> REPLACE DETERIORATED POLE <br /> 37.94708,-121.22427 <br /> 4728 4TH ST.,STOCKTON,CA 95215 <br /> Work will commence on or about for approximately 1` 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 /> PyWDALL WA 08/14/15 <br /> Signature of Applicant-Title Date <br /> M:ICENTRALSERVICES,CLERICAL'R18SV.WMAAASTER.PSENCROACHMENTPERMfr APPUCATION.DOC (09113) <br />