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APPLICATION FOR ENCROACHMENT PERMIT <br /> PLEASE PRINT: <br /> Date �/f �� OFFICE USE ONLY <br /> To: San Joaquin County JOB# 7 3 U(f f REF# <br /> Department of Public Works APN CR# <br /> EXP.DATE - <br /> PG&E VALID I-1 TO - DRIVEWAYS: <br /> (Applicant Name) STREET _ x <br /> 4040 WEST LN AREA QUAD _n!C <br /> TYPE <br /> (Mailing Address) FORMS <br /> STOCKTON, CA 95204 NOTES <br /> (City,State,Zip Code) <br /> 408-316-1767 <br /> (Area Code-Telephone Number) <br /> Sketch(Detailed plans may be submitted) <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 EP 1 side of JONMSW ft. approximately 21 620` feet/mile <br /> of 9oUrtt OF HW`( 1-2, , <br /> W tiA� by performing the following work(description of work): <br /> ppLE 1NSTAl.-ti—�Tl t�t�l Tk4� N,Ct-t 0 <br /> Work will commence on or about 14ORTW OF OCTB B 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 /> 0 6LN-N t e� floes ct `t' - Is-- 15; <br /> Signature of Applicant-Title Date <br /> Ewuasv.Vvar.!ASTEarstEuCROACH�,St(r W,'ITAaaucnnou.00c(010) <br />