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APPLICATION FOR ENCROACHMENT PERMIT <br /> PLEASE PRINT: <br /> ns - 4-3 <br /> Date 4/24/2014 OFFICE USE ONLY <br /> To: San Joaquin County JOB# ( ( G'CC REF# <br /> Department of Public Works APN CR# <br /> EXP.DATE 1 <br /> Rubik Environmental VALID / /1 0- TO DRIVEWAYS: <br /> (Applicant Name) STREET <br /> AREA S. n ,�. QUAD /1 <br /> 320 Flint Street TYPE <br /> (Mailing Address) FORMS 5 Vk/j +,j4/ <br /> NOTES <br /> Reno,Nevada 89501 <br /> (City,State,Zip Code) <br /> (775) 622-0857 <br /> (Area Code-Telephone Number) <br /> Sketch(Detailed plans may be submitted) <br /> See Figure for monitoring well locations <br /> The undersigned hereby applies for permission to excavate,construct and/or otherwise encroach on County Highwa Right-of-Way on <br /> the South side of Lewis Street approximately 78 fee mile East <br /> of Golden Gate Avenue , Stockton , by performing the following work ription of work): <br /> Uncover a paved over monitoring well and setting a new well box at the new grade.The area surrounding the <br /> new well box will be hot patched. <br /> Work will commence on or about May 12, 2014 for approximately 1 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 /> 4/24/2014 <br /> Signature of Applicant-Title Date <br /> Stephen A. Meninger, PG Senior Geologist <br /> MICENTRALSERVICESICLERICALIPUB-SV.WKIMASTER.PSIENCROACHMENTPERMITAPPLICATION.WC (09113) <br />