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APPLICATION FOR ENCROACHMENT PERMIT <br /> PLEASE PRINT: 1 / 00 C <br /> Date January 15,2014 OFFICE USE ONLY <br /> To: San Joaquin County JOB# (1 V 0 V REF# <br /> Department of Public Works APN CR# <br /> EXP.DATE 37is/i* <br /> CardnOATC VALID z-/ TO icy/1 DRIVEWAYS: <br /> (Applicant Name) STREET <br /> AREA 5 QUAD I(( <br /> 1117 Lone Palm Avenue Suite 201 TYPE Dcvite5 <br /> (Mailing Address) FORMSS Wl✓ <br /> NOTES <br /> Modesto,California 95351 <br /> (City,State,Zip Code) <br /> (209)579-2221 <br /> (Area Code-Telephone Number) <br /> Sketch(Detailed plans may be submitted) <br /> Destruction of groundwater wells in the county's right-of-way. <br /> See figure -Traffic control plan for location of wells and lane closure. <br /> The undersigned hereby applies for permission to excavate,construct and/or otherwise encroach on County Highway Right-of-Way on <br /> the west side of Pershing approximately 200 feet/mile <br /> of Country Club Blvd.and Elmwood Avenue ,by performing the following work(description of work): <br /> Destruction of the monitoring wells installed within the County of San Joaquin's maintained roadways.Three wells are within the County of San Joaquin's maintained roadways <br /> -two within Elmwood Avenue and one well within Country Club Boulevard. <br /> Work will commence on or about Feb 11-12(air knifing)and Feb 18-19(overdrilling) for approximately 1.5 days air knife and 1.5 days overdrill 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 /> Signat re of Applic t-Title Date <br /> E.iPUB-SV.WKV,WSTERPSIENCROACHIdENTPERLllTAPPLICATION.DOC(OWB) <br />