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t <br /> APPLICATION FOR ENCROACHMENT PERMIT <br /> PLEASE PRINT: <br /> Date December 21, 2011 OFFICE USE ONLY <br /> To: San Joaquin County JOB# PVJP 130 aZ-Zd REF# <br /> Department of Public Works APN CR# <br /> �--(- <br /> Pacific Gas& Electric c/o Ajsha PullinEXP.DATE 20 12_ <br /> ?�b( IZTO ,�-�-Z�Z DRIVEWAYS: <br /> (Applicant Name) STREET , Qom. <br /> AREA QUAD _ <br /> 375 N. Wicret Lane Ste 200 TYPE 1('e <br /> (Mailing Address) FORMS 3 <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 undersi neJ� reby applies for permission to excavate,construct and/or otherwise encroach on County Highway Right-of-Way on <br /> the �i �✓ side of S. � <br /> Lammar Road approximately 2, 89 6 feet/mile bk <br /> of Valpico Rd by performing the following work(description of work): <br /> Indirect survey of gas pipeline to assess corrosion protection. Survey <br /> consists of drilling 1/2 " 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 2/1/2012 for approximately 20 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 /> ature of Applicant-Title Date <br /> E:IPUS-SV.WNIMASTERPSIENCROACHMENTPERMITAPPLICATION.DOC (OMB) <br />