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APPLICATION FOR ENCROACHMENT PERMIT <br /> PLEASE PRINT: <br /> Date December 21, 2011 OFFICE USE ONLY <br /> To: San Joaquin County JOB# ln�'�, C:6��(S REF# <br /> Department of Public Works APN CR# <br /> EXP.DATE <br /> Pacific Gas& Electric c/o Ajsha Pullin VALID 2 l ^?1�'iZTO :5-t-20A 2_, DRIVEWAYS: <br /> (Applicant Name) STREET Lk)e&A <br /> ,Pd(r} <br /> AREA iVj N cq QUAD <br /> 375 N Wiaet Lane Ste. 200 TYPE <br /> (Mailing Address) FORMS s5/to k.J QZ q <br /> NOTES <br /> Walnut Creek, CA 94598 <br /> (City,State,Zip Code) <br /> (925) 323-0904 <br /> (Area Code-Telephone Number) <br /> Sketch (Detailed plans may be submitted) <br /> See attachments <br /> The undersigned hereby applies for permission to excavate,construct and/or otherwise encroach on County Highway Right-of-Way on <br /> the North sideof W. Ripon Road approximately 400 ft feet/mile" <br /> of S. Manteca Rd by performing the following work(description of work): <br /> Indirect survey of gas pipeline to assess corrosion protection. Survey <br /> consists of drilling 1/21, holes every 10 , along pipe path where AC is cover. <br /> No excavation required. Please see attached for more details . <br /> Work will commence on or about 2/3/2 012 for approximately 17 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 /> 12/21/2011 <br /> Signature of Applicant-Title Date <br /> E:1PUB-SV.WKIMASTER.PMENCROACHMENT PERMIT APPLICATION.DOC(01108) \ <br />