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APPLICATION FOR ENCROACHMENT PERMIT <br />PLEASE PRINT: <br />Date %% 4'e //--7" <br />OFFICE USE ONLY <br />To: San Joaquin County <br />JOB # <br />73 r, S REF # <br />Department of Public Works <br />APN <br />CR # <br />PG&E <br />EXP. DATE <br />VALID <br />STREET <br />TO DRIVEWAYS: <br />(Applicant Name) <br />4040 West Lane <br />AREA <br />QUAD <br />TYPE <br />(Mailing Address) <br />FORMS <br />Stockton, CA. 95204 <br />NOTES <br />(City, State, Zip Code) <br />(209) 409-2083 <br />(Area Code - Telephone Numbe <br />WAT80IPGE.001Vl <br />(Email Address) <br />Sketch (Detailed plans may be <br />SEE ATTACHE® DRAWING <br />PM# y30S,1? ej- <br />The undersigned hereby applies for permission to. excavate, construct and/or otherwise encroach on County Highwa Right -of -Way on <br />the S side of alai wUo di� vt approximately 624 mIle W <br />Of_�?e'.-� ;via Ave S��-,��n,byperforming the following work (description ofwork): <br />Nr4ria will commence on or after JoZ R fnrapprordmately /2 f days. <br />f, 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 />/ AL <br />Signature fApplic t -Title ' Date <br />PVORM58 iEMPLWSENCROg HM ENT PERMIT APPLICATION&v(OMq <br />