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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# 730D5'2:(-_ REF# <br /> Department of Public Works APN CR# <br /> EXP.DATE <br /> PG&E VALID Idli fi3 TO It 3 DRIVEWAYS: <br /> (Applicant Name) STREET 6ewuCtz 'ed. <br /> AREA QUAD 5W <br /> 4040 WEST LN TYPE V` Rap- <br /> (MailingAddress) FORMS M4 2 <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 41925815 <br /> The undersigned hereby applies for permission to excavate, construct and/or otherwise encroach on County Highway Right-of-Way on <br /> the SOUTH side of W SCHULTE RD approximately 375 ' feet/mile_E/O <br /> of _ MACARTHUR DR 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.IPUB-SV.WKIMASTER.PSIENCROACHMENT PERMIT APPLICATION.DOC (01108) <br />