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APPLICATION FOR ENCROACHMENT PERMIT <br /> PLEASE PRINT: <br /> Date 3/8/2013 OFFICE USE ONLY <br /> To: San Joaquin County JOB# 54e_�3v_6 REF# <br /> Department of Public Works APN CR# <br /> EXP.DATE1157W <br /> PG&E VALID ,3 T-6 /5'13 DRIVEWAYS: <br /> (Applicant Name) STREET Ae� <br /> 4040 WEST LANE AREA S`rG//,72 QUAD <br /> TYPE -F:a; <br /> (Mailing Address) FORMS -Z <br /> � <br /> STOCKTON, CA 95204 NOTES <br /> (City,State,Zip Code) <br /> 209-942-1421 <br /> (Area Code-Telephone Number) <br /> Sketch(Detailed plans may be submitted) <br /> SEE ATTACHED <br /> PM 41863364 <br /> The undersigned hereby applies for permission to excavate,construct and/or otherwise encroach on County Highway Right-of-Way on <br /> the S side of INMAN AVE & MONTEREY AVE.approximately VARIOUS feet/mile <br /> of , STOCKTON , by performing the following work(description of work): <br /> POT HOLE 3 LOCATIONS ON INMAN AVE AND 3 LOCATIONS ON MONTEREY AVE TO <br /> VERIFY WHETHER OR NOT THE GAS FACILITIES WILL BE IN CONFLICT WITH THE <br /> Si COUNTY ROAD IMPROVEMENT PROJECT. <br /> Work will commence on or about 3/2 5/2 013 for approximately 5 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 /> ,r 3/8/2013 <br /> ignature of Applicant-Title Date <br /> E:IPUB•SV.WKIMASTER.PSIENCROACHMENTPERMIT APPLICATION.DOC (0%8) <br />