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APPLICATION FOR ENCROACHMENT PERMIT <br /> PLEASE PRINT: <br /> Feb. 28, 2012 <br /> Date OFFICE USE ONLY <br /> To: San Joaquin County JOB# �,�Q�� REF# <br /> Department of Public Works APN CR# <br /> East Bay Municipal Utility District(EBMUD) EXP.DATE <br /> VALID �; ;Z TO DRIVEWAYS: <br /> (Applicant Name) STREET i?-,,n,1 �T <br /> P.O. Box 228 <br /> AREA Cj�r�1e- QUAD IJP <br /> TYPE Tra' ,� Cv^•�c�1 �,r , <br /> (Mailing Address) FORMS <br /> Stockton, CA 95201 NOTES <br /> (City,State,Zip Code) <br /> 209-946-8009 P b,6(!Ao <br /> (Area Code-Telephone Number) <br /> Sketch(Detailed plans may be submitted) <br /> See attached plans <br /> The undersigned hereby applies for permission to excavate, construct and/or otherwise encroach on County Highway Right-of-Wav on <br /> the_various side of various approximately various feet/mile—various _ <br /> of by performing the following work(description of work): <br /> —East Bay Municipal Utility District(EBMUD)operates a 72-inch raw water transmission pipeline from Clay Station Road to Cord <br /> —Road, terminating at the EBMUD Mokelumne,Aqueducts. On a periodic and/or emergency basis, EBMUD will perform operations <br /> —and maintenance, inspections and monitoring of pipeline appurtenances such as valves. EBMUD staff will need to access vaults and <br /> —other appurtenances along various roads and road shoulders. <br /> Work will commence on or about _ 5� !� for approximately days. <br /> I,the undersigne , rtify that I am the owner of the respective property,or am qualified to represent the owner and agree to do the <br /> work described bov in accordance with the rules and regulations of San Joaquin County and subject to inspection and approval. <br /> , Wrelof Applicant-Title Date <br /> E:IPUB&SVWKWASTERPSIENCROACHhENT PERMIT APPLICATION.DOC (01108) <br />