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APPLICATION FOR ENCROACHMENT PERMIT <br />PLEASE PRINT: <br />Date 6/25/2015 OFFICE USE ONLY <br />To: San Joaquin County JOB#7 3 D0 SZ REF# <br />Department of Public Works APN CR# <br />PG&E EXP.DATE=11-1 -15 <br />VALID 10-I0-1S TO DRIVEWAYS: <br />Applicant Name) STREET 5-fa bey Ac4 <br />850 STILLWATER DR. TYPE QUAD — <br />Mailing Address) FORMS SSWIa/ <br />WEST SACRAMENTO, CA 95605 NOTES <br />City, State,Zip Code) <br />C[ `" - "cl ' r <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 ontheRIGHTsideofHWY4approximatelyfeet/mileofbyperformingthefollowingwork(description of work):REPLACE DETERIORATED POLE; MAKE MINOR EXCAVATION WITHIN COUNTY RIGHT-OF-WAYS <br />EXCAVATION SHALL NOT EXCEED 35SQ FT IN AREA AND NOT GREATER THAN 6 LINEAR FT IN LENGTH <br />Work will commence on or about 10/10/2015 for approximately 1-4 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 theworkdescribedaboveinaccordancewiththerulesandregulationsofSanJoaquinCountyandsubjecttoinspectionandapproval. <br />6/25/2015 <br />Signature o Applicant-Title Date <br />E?PUB-SV.WKWASTER.PSIENCROACHMENTPERMITAPPLICATION.DOC (01108)