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APPLICATION FOR ENCROACHMENT PERMIT <br />PLEASE PRINT: <br />Date 4/1/2014 <br />To: San Joaquin County <br />Department of Public Works <br />PG&E <br />(Applicant Name) <br />4040 West Ln <br />(Mailing Address) <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 />C . HfA ' <br />Z v � - ?-12--1 Lt 2-C <br />See attached sketch <br />PM 31066407 <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 Larch Rd <br />approximately 1719' feet/mile West <br />of N Tracy Blvd , Tracy , by performing the following work (description of work): <br />Excavate (1) 4'X4' bellhole and trench 22' to the south property line to <br />replace gas service to 10928 W Larch Rd, Tracy <br />Work will commence on or about 4/7/2014 for approximately <br />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 />4/1/2014 <br />Xig-oe�f� Applicant - Title Date <br />E.IPUB-SVWMMASTERPMENCROACHMENT PERMIT APPLICATIONLOC (01108) <br />OFFICE USE ONLY <br />JOB # <br />'�yS2REF # <br />APN <br />CR # <br />EXP. DATE <br />L7— <br />VALID <br />- - TO �j'-/�.. ( DRIVEWAYS: <br />STREET <br />(f <br />AREA <br />'TY QUAD <br />TYPE <br />FORMS <br />NOTES <br />55 <br />/ <br />See attached sketch <br />PM 31066407 <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 Larch Rd <br />approximately 1719' feet/mile West <br />of N Tracy Blvd , Tracy , by performing the following work (description of work): <br />Excavate (1) 4'X4' bellhole and trench 22' to the south property line to <br />replace gas service to 10928 W Larch Rd, Tracy <br />Work will commence on or about 4/7/2014 for approximately <br />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 />4/1/2014 <br />Xig-oe�f� Applicant - Title Date <br />E.IPUB-SVWMMASTERPMENCROACHMENT PERMIT APPLICATIONLOC (01108) <br />