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APPLICATION FOR ENCROACHMENT PERMIT <br /> PLEASE PRINT: RECEIVED <br /> Date 10/5/2012 OFFICE USE ONLY <br /> To: San Joaquin County JOB# 13aas--S REF# <br /> Department of Public Works FRESNO APN CR# <br /> OMD/ PD EXP.DATE / ; <br /> PG&E (KAMRAN VAHABI VALID 1 13 To 4 , I3 DRIVEWAYS: <br /> (Applicant Name) STREET HWjC&,M&I; g�, f <br /> AREA QUAD .% <br /> 8 RIVER PARK PLACE EAST TYPE 0L6S S <br /> (Mailing Address) FORMS <br /> FRESNO, CA, 937210 NOTES <br /> (City,State,Zip Code) <br /> 559-347-5052 <br /> (Area Code-Telephone Number) <br /> Sketch(Detailed plans may be submitted) <br /> CONFLICTS. 50 START CONSTRUCTION: 11-1-12 <br /> SEE ATTACHED DRAWING. END CONSTRUCTION: 12-31-13 <br /> PM 30649126 <br /> The undersigned hereby applies for permission to excavate, construct and/or otherwise encroach on County Highway Right-of-Way on <br /> the EAST side of FRONTAGE RD approximately 580 FEET feet/mile NORTH <br /> of MARFARGOA DR , by performing the following work(description of work): <br /> EXCAVATE 3 BELL HOLES AND INSTALL 290'OF GAS MAIN <br /> 2 BELL HOLES AT 580'AND 770'NORTH OF MARFARGOA DR ON FARMINGTON RD. <br /> INSTALL 290'OF 2"GAS MAIN <br /> Work will commence On Or about SCHEDULE TO BE DETERMINED BY CALTRANS for approximately 3 DAYS days. <br /> (LAST QUARTER OF 2012,FIRST QUARTER OF 2013) <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 /> 10/5/2012 <br /> Signature of Applicant-Title Date <br /> E:IPUB-SV.WKIMASTER.PSIENCROACHMENT PERMIT APPLICATION.DOC (01/08) <br />