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APPLICATION FOR ENCROACHMENT PERMIT <br /> PLEASE PRINT: <br /> Date OFFICE USE ONLY <br /> To: San Joaquin County JOB# 1 REF# <br /> Department of Public Works APN CR# <br /> C/ EXP.DATE <br /> BRYAN GORDON. U' (��? f VALID 1L- l S TO _1.14 DRIVEWAYS: <br /> (Applicant Name) STREET 0Ar1/'yC41- 854 <br /> AREA 1-h <br /> 850 STILLWATER RDTYPE —gm 4- QUAD <br /> (Mailing Address) <br /> FORMS S Gr/In/ <br /> 1 �� , r � 1)0� OL NOTES <br /> /`J <br /> (City,State,rZiip'Code) <br /> 925-327-0990 <br /> (Area Code-Telephone Number) <br /> Sketch(Detailed plans may be submitted) <br /> POLE REPLACEMENT <br /> The undersigned hereby applies for permission to excavate,construct and/or otherwise encroach on County Highway Right-of-Way on <br /> the NORTH side of W WnnnRlnnF Rn approximately feet/mile <br /> of by performing the following work(description of work): <br /> Work will commence on or about 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 /> BRYAN GORDON 09/24/2015 <br /> Signature of Applicant-Title Date <br /> M:ICENTRALSERV10ES',CLERICAL`PUB-SV.WK`IMASTER.PSENCROACNMENTPERMRMPLICATION.DOC (09113) <br />