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APPLICATION FOR ENCROACHMENT PERMIT <br /> PLEASE PRINT: <br /> Date February 10, 2014 OFFICE USE ONLY <br /> To: San Joaquin County JOB# U U 0 q REF# <br /> Department of Public Works APN CR# <br /> East Bay Municipal Utility District(EBMUD) EXP,DATE I <br /> VALID TO DRIVEWAYS: <br /> (Applicant Name) STREET Ra( * <br /> 1804 W. Main Street AREA Lodi — QUAD A_ <br /> TYPE <br /> (Mailing Address) FORMS �� <br /> Stockton, CA 95203 NOTES <br /> (City,State,Zip Code) <br /> 209-946-8007 <br /> (Area Code-Telephone Number) <br /> Sketch(Detailed plans may be submitted) See attached plans <br /> The undersigned hereby applies for permission to excavate,construct and/or otherwise encroach on County Highway Right-of-Way on <br /> the various side of various approximately various feet/mile <br /> of <br /> by performing the following work(description of work): <br /> East Bay Municipal Utility District(EBMUD)operates a 72-inch raw water transmission pipeline from Clay Station Road <br /> to Cord Road terminating at the EBMUD Mokelumne Aqueducts On eriodie and/or m r <br /> P ��ggncy basis, EBMUD will <br /> perform operations and maintenance, inspections and monitoring of pipeline appurtenances such as valves. EBMUD <br /> staff will need access to vaults and other appurtenances along various roads and road shoulders. <br /> Work will commence on or aboutQUI t� G for approximately 1 hour-5 days days. <br /> `f 19 <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 /> 4S' ature pplicant-Title Date <br /> M.ICENTRALSERVICESICLERICALIPUBSV.WK"STER.PSIENCROACHNENTPERMITAPPLICATION.DOC(09/13) <br />