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APPLICATION FOR ENCROACHMENT PERMIT <br /> PLEASE PRINT: <br /> Date February 22, 2 013 OFFICE USE ONLY <br /> To: San Joaquin County JOB# REF# <br /> Department of Public Works APN CR# <br /> EXP.DATE -flIS1,13 <br /> Pacific Gas& Electric c/o Ajsha Pullin VALID T / ,� DRIVEWAYS: <br /> (Applicant Name) STREET <br /> AREA 604znP.Sjuo6d QUAD AW <br /> 375 N. Wiget Lane Ste. 200 TYPE 6A6 A0&14_ !l1 <br /> (Mailing Address) FORMS �S,wW <br /> NOTES <br /> Walnut Creek, CA 94598 <br /> (City,State,Zip Code) <br /> (92 5) 323-0904 <br /> (Area Code-Telephone Number) <br /> Sketch(Detailed plans may be submitted) <br /> See attachments <br /> The undersigned hereby applies for permission to excavate,construct and/or otherwise encroach on County Highway Right-of-Way on <br /> the North side of Mokelumne Street approximately 276 feet/mile East <br /> of E Woodbridge Rd ,by performing the following work(description of work): <br /> Indirect survey of gas pipeline to assess corrosion protection. Survey <br /> consists of drilling 1/2" holes every 10 ' along pipe path where AC is cover. <br /> No excavation required. Please see attached for more details . <br /> Work will commence on or about 3/6/2013 (TBD) 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 /> 2/22/2013 <br /> nature of Applicant-Title Date <br /> IPUB-SV.WKIMASTER.PSIENCROACHMENTPERNTAPPUCATION.DOC (01108) <br />