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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# REF# <br /> Department of Public Works APN CR# <br /> EXP. DATE t <br /> PG&E VALID 4 14 A 0 B DRIVEWAYS: <br /> (Applicant Name) STREET &'W rf, 0. <br /> AREA AcA M P6, 9UAD R <br /> 4040 WEST LN TYPE aj c, (6Ff gAgLA6 -s <br /> (Mailing Address) FORMS wv� Z9 <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 42096723 <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 124' feet/mile 91=0 6A;&I- <br /> of NICHOLS 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 4/14/2014 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 /> , 4 �c <br /> 4/8/2014 <br /> Signatu of Applicant-Title Date <br /> E:1PUB-SV.WK\MASTERPSIENCROACHMENT PERMIT APPLICATION.DOC (01/00) <br />