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APPLICATION FOR ENCROACHMENT PERMIT <br />PLEASE PRINT: <br />Date 08/03/2015 OFFICE USE ONLY <br />To: San Joaquin County JOB# c REF#Department of Public Works APN CR# <br />EXP.DATE <br />JAMES SMALL VALID <br />Applicant Name) STREET <br />4 6 DRIVEWAYS: <br />R <br />AREA 1na C QUAD/2700 MERGED ST TYPE <br />Mailing Address) FORMS 4 f <br />SAN LEANDRO, CA 94577 <br />NOTES <br />City,State,Zip Code) <br />916)207-3637 <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 onthe_ <br />1 <br />z) <br />WEST side of S LAMMERS ROAD approximatelyI 1ofW.SCHULTE ROAD feet/mile_No;z _SAN JOAQUIN COUNTY by performing the following work(description of work):l', i1-"t 'v ASS 'js! <br />0r Ow UZ( 4NJ E14Af : tel) !'L c y13gr <br />c' i..: <br />L <br />pc <br />Work will commence on or about for approximately 3O 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 />Si u f Applicant-Title f.3 Z7f <br />Date <br />E:PU&SV.WKIMASTER.PSIENCROACHMENTPERMRAPPLICATION.DOC (01/08)