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APPLICATION FOR ENCROACHMENT PERMIT <br /> PLEASE PRINT: <br /> Date 9-10-12 OFFICE USE ONLY <br /> To: San Joaquin County JOB# 2?,Yj�l� F# <br /> Department of Public Works APN REF <br /> # <br /> EXP.DATE 5-//.3 <br /> Calaveras Telephone VALID %( /Z- 0 S DRIVEWAYS: <br /> (Applicant Name) STREET M go <br /> AREA I iv DE 4 QUAD _ <br /> PO Box 37 TYPE e <br /> (Mailing Address) FORMST <br /> Copperopolis, Ca. 95228 NOTES <br /> (City,State,Zip Code) <br /> 209-785-2211 <br /> (Area Code-Telephone Number) <br /> Sketch(Detailed plans may be submitted) <br /> The undersigned hereby applies for permission to excavate,construct and/or otherwise encroach on County Highway Right-of-Way on <br /> the East&West side of Duncan Rd. 6,250ft.UG/10,350ft.Aerial <br /> approximately feet/mile <br /> of new(2)1.25"SCH40 conduits&aerial cable placement by performing the following work(description of work): <br /> Calaveras telephone proposes to place new conduit structure&aerial cable attachment from the intersection of Hwy.26&Duncan Rd.to the intersection Duncan Rd.&Copperopolis Rd. <br /> Work will commence on or about', /tofor approximately D 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 /> E CA—, a D 0 9-10-12 <br /> Signature of Applicant-Title Date <br /> E:IPUB-SV.WKIMASTER.PSIENCROACNMENTPERMITAPPUCATION.DOC(01100) <br /> P S -- I2 - -; 4-1- <br />