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t <br /> ps- <br /> APPLICATION FOR ENCROACHMENT PERMIT <br /> PLEASE PRINT: <br /> Date 12/l/2012 OFFICE USE ONLY <br /> To: San Joaquin County JOB# �J,3010~2- ,� REF# <br /> Department of Public Works APN CR# <br /> EXP.DATE (Q 1 <br /> PG&E VALID $ T6 61157111 DRIVEWAYS: <br /> (Applicant Name) STREET 13 iA Co <br /> 4040 West Lane TRPS QUAD 5w <br /> (Mailing Address) FORMS Ss - <br /> NOTES <br /> Stockton, CA 95204 <br /> (City,State,Zip Code) -Co id Vf6 <br /> 209-942-1421 <br /> (Area Code-Telephone Number) <br /> Sketch(Detailed plans may be submitted) <br /> *This work is being done at the request of <br /> San Joaquin County to clear proposed signal <br /> lights . Contact Michael Chung (SJ County <br /> Engineer) <br /> See Attached Plans <br /> PM# 30956038 <br /> The undersigned hereby applies for permission to excavate,construct and/or otherwise encroach on County Highway Right-of-Way on <br /> the West side of Byron Rd. approximately feet/mile <br /> of @ Grantl7ine Rd—. Tracy , by performing the following work(description of work): <br /> Trench 270 ' on the west side of Byron rd. to relocate existing gas line <br /> to clear proposed signal light locations . <br /> Work will commence on or about 4/l/2013 for approximately 60 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 /> /�SSDL /5T �ClG2 <br /> 12/l/2012 <br /> Signature of Applicant-Title Date <br /> E:IPUBSV.WKIMASTER.PSiENCROACHMENT PERMIT APPLICATION.DOC(01108) <br />