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APPLICATION FOR ENCROACHMENT PERMIT <br /> PLEASE PRINT: <br /> Date 4/8/2014 OFFICE USE ONLY <br /> To: San Joaquin County JOB# -73,405,z-4. REF# <br /> Department of Public Works APN CR# <br /> EXP. DATE 1 <br /> PG&E VALID 4 TO /Q DRIVEWAYS: <br /> (Applicant Name) STREET try R <br /> AREA QUAD Alg <br /> 4040 WEST LN TYPE 7;P-L[.Hz-E OFFI�YkFr�7� <br /> (Mailing Address) FORMS l�►,w. 2-29 <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 SKETCH <br /> PM 42096722 <br /> The undersigned hereby applies for permission to excavate, construct and/or otherwise encroach on County Highway Right-of-Way on <br /> the NORTH side of LIBERTY RD approximately 190' feet/mile EAST <br /> of HWY 99 FRONTAGE RD , GALT , by performing the following work(description of work): <br /> EXCAVATE (1) 5'x5' BELLHOLE TO PERFORM MAINTENANCE ON AN EXISTING GAS SERVICE. <br /> Work will commence on or about 4/14/2 014 for approximately 60 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 /> 1/1 J�9_- 4/8/2014 <br /> tvlure of Applicant-Title Date <br /> E1PUB-SV.WKIMASTERPSIENCROACHMENT PERMIT APPLICATION.DOC (01/08) <br />