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APPLICATION FOR ENCROACHMENT PERMIT <br /> PLEASE PRINT: <br /> Date 9/24/2013 OFFICE USE ONLY <br /> To: San Joaquin County JOB# 73Gb`j�-Co REF# <br /> Department of Public Works APN CR# <br /> EXP.DATE <br /> PG&E VALID t0 DRIVEWAYS: <br /> (Applicant Name) STREET _ S-`', <br /> AREA -rtAcy QUAD SLA <br /> 4040 WEST LN TYPE -$EL Hoa- <br /> (Mailing <br /> o -(Mailing Address) FORMS <br /> NOTES <br /> STOCKTON, CA 95204 <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 41925391 <br /> The undersigned hereby applies for permission to excavate, construct and/or otherwise encroach on County Highway Right-of-Way on <br /> the SOUTH sideof E 11TH ST approximately 750 ' feet/mile W/O <br /> of CARE. RT). TRACY , by performing the following work(description of work): <br /> EXCAVATE (1) 5 'x5 ' BELLHOLE TO PERFORM MAINTENANCE ON EXISTING GAS MAIN <br /> Work will commence on or about 10/1/2 013 for approximately 31 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 /> 9/24/2013 <br /> Signature of Applicant-Title Date <br /> E:NUB-SV.WKIMASTER.PSIENCROACHMENTPERNTAPPLICATION.DOC (01108) <br />