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APPLICATION FOR ENCROACHMENT PERMIT <br /> PLEASE PRINT: <br /> Date 4/7/2014 OFFICE USE ONLY <br /> To: San Joaquin County JOB# 73ag52— REF# <br /> Department of Public Works APN CR# <br /> EXP.DATES 1 4 <br /> PG&E VALID TOhJM DRIVEWAYS: <br /> (Applicant Name) STREET _1.4 <br /> AREA LX QUAD <br /> 4040 WEST LN TYPE u- 1E <br /> (Mailing Address) FORMS "Im)ml, ,'°2S -rlex ,ny <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 42100323 <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 approximately 785feet/mile WEST <br /> of N TRACY BLVD , TRACY , by performing the following work(description of work): <br /> EXCAVATE (1) 5 'x5' BELLHOLE TO PERFORM MAINTENANCE ON AN EXISTING STEEL GAS MAIN. <br /> Work will commence on or about 4 /1 4/2 D 1 4 for approximately 9 0 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 /> 4/7/2014 <br /> Sigheure oY Applicant-Title Date <br /> E:PUB-SV.WMMASTER.PSIENCROACHMENT PERMIT APPLICATION.DOC (01108) <br />