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APPLICATION FOR ENCROACHMENT PERMIT <br /> PLEASE PRINT: <br /> Date 5/6/2014 <br /> OFFICE USE ONLY <br /> To: San Joaquin County JOB# 7 3 00 5'2- REF# <br /> Department of Public Works APN CR# <br /> PG&E EXP.DATE (0 ( <br /> VALID �,/;(, TO .1011714 DRIVEWAYS: <br /> (Applicant Name) STREET C tar k [>p- <br /> 4040 <br /> r4040 West Ln AREA 5f#r <br /> [k toll QUAD E S <br /> TYPE <br /> (Mailing Address) FORMSIth Ch <br /> 5 Z /W _R I 11-M(A Olff'0 ' <br /> Stockton, CA, 95204 NOTES <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 31074265 <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 Clark Dr approximately 170' <br /> pP Y feet/mile East <br /> of _ Hwy 99 Frontage Rd , Stockton _ by performing the following work(description of work): <br /> Excavate (1)4'x4'bellhole to deactivate an idle gas service. <br /> Work will commence on or about 6/15/2014 for approximately 90 days 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 /> 5/6/2014 <br /> Signature of Applicant-Title Date <br /> E:IPUB-SV.WKUMSTER.PSIENCROACHMENT PERMIT APPLICATION.DOC (01/08) <br />