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APPLICATION FOR ENCROACHMENT PERMIT <br /> PLEASE PRINT: <br /> Date April 4, 2011 , ,O,yFFFIICE USE ONLY <br /> To: San Joaquin County JOB# /DD�7�# REF# <br /> Department of Public Works APN CR# <br /> EXP.DATE r3 <br /> Mountain Cascade, Inc VALID 0 fo DRIVEWAYS: <br /> (Applicant Name) STREET E,e ,Q <br /> AREA QUAD 5141 ' <br /> PO BOX 5050 TYPE ZAt57M& " g�5 <br /> (Mailing Address) FORMS <br /> NOTES <br /> Livermore, CA 94551 <br /> (City,State,Zip Code) <br /> 925-373-8370 <br /> (Area Code-Telephone Number) <br /> Sketch(Detailed plans may be submitted) <br /> See attached Traffic Control Plans for pipeline installation for Bird <br /> Road, Koster Road, and Bernard Drive for the San Joaquin Pipeline System <br /> Western Segment Project for the SFPUC. <br /> 06 O <br /> The undersigned hereby applies for permission to excavate,construct and/or otherwise encroach on County Highway Right-of-Way on <br /> the side of_ approximately feet/mile_ <br /> of ,by performing the following work(description of work): <br /> Bird Road, Koster Road, and Bernard Drive <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 /> oKawx ��� - P rD t-ct April 4, 2011 <br /> Signature of Applicant- itle 60rd � l Date <br /> .'PUB SV.W/.WSTERPSEIICROACHWIfT PERIAT APPUCATIM DOC(014,4( <br />