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APPLICATION FOR ENCROACHMENT PERMIT <br /> PLEASE PRINT: <br /> Date 5/31/2014 OFFICE USE ONLY <br /> To: San Joaquin County JOB# 732 REF# <br /> Department of Public Works APN CR# <br /> EXP.DATE fy-t-2 v 1 q <br /> PG&E VALID -k-Zvi TO l of— DRIVEWAYS: <br /> (Applicant Name) STREET �" Z, 2c <br /> 4040 WEST LN AREA 51601 11 QUAD Sk,"") <br /> TYPE <br /> (Mailing Address) FORMS 55 <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 31047342 <br /> The undersigned hereby applies for permission to excavate, construct and/or otherwise encroach on County Highway Right-of-Way on <br /> the WEST side of STARK RD _approximately feet/mile <br /> of AT MUELLER RD STOCKTON , by performing the following work(description of work): <br /> EXCAVATE (1) 5'x5' BELLHOLE TO REPLACE EXISTING GAS SERVICE. <br /> Work will commence on or about 7/1/2014 for approximately 90 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 /> �' 04� 5/31/2014 <br /> ure of pplicant-Title Date <br /> E:1PUB-SV.WKWASTERPS\ENCROACHMENT PERMIT APPLICATIONAOC (01/08) <br />