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APPLICATION FOR ENCROACHMENT PERMIT <br /> PLEASE PRINT: <br /> Date 5/7/2013 OFFICE USE ONLY <br /> To: San Joaquin County JOB# �3J',�•�P REF# <br /> Department of Public Works APN CR# <br /> EXP.DATE k <br /> PG&E VALID 1 0 DRIVEWAYS: <br /> (Applicant Name) STREET Q p �� <br /> 4040 WEST LN AREA Lal}64 V QUAD <br /> TYPE t'3Et-- &A " <br /> (Mailing Address) FORMS w �@ <br /> STOCKTON, CA 95204 NOTES Q 1 <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 30953681 <br /> The undersigned herebyif4pa for ermission to excavate,construct and/or otherwise encroach on County Highway Right-of-Way on <br /> the s RC ARD RD. <br /> approximately 7 8 0 feet/mile WEST <br /> of BUCK RD. ACAMPO , by performing the following work(description of work): <br /> EXCAVATE (1) 51x5' BELLHOLE AND TRENCH 50' ACROSS E. ORCHARD RD. TO REPLACE THE GAS <br /> SERVICE SERVING 9522 E ORCHARD RD. <br /> Work will commence on or about 1/1/2014 for approximately 180 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 /> 5/7/2013 <br /> Signature of pplicant-Title Date <br /> E:IPUB-SV.WKIMASTER.PSIENCROACHMENTPERMIT APPLICATION.DOC(01/08) <br />