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APPLICATION FOR ENCROACHMENT PERMIT <br /> PLEASE PRINT: p S �ZQ C� 3 S <br /> Date 5/1/2014 OFFICE USE ONLY <br /> To: San Joaquin County JOB# 7' QQ S Z REF# <br /> Department of Public Works APN _ CR# <br /> EXP. DATE 1O/ 4 <br /> PG&EDRIVEWAYS: <br /> VALID 6� TO l(0/11(f <br /> (Applicant Name) STREET __Al ulh S+ <br /> AREA " ktQ" _ QUAD f <br /> 4040 West Ln TYPE - <br /> (Mailing Address) FORMS W W - `� /�Tv+e�ch C,-1fin9 <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 31072886 <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 E Main St approximately 112' feet/mile West <br /> of S. Olive Ave Stockton , by performing the following work(description of work): <br /> Excavate (1)5'x5' bellhole in the right eastbound lane in order to deactivate an existing 1/2" plastic gas line. <br /> Work will commence on or about 6/1/2014 _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 /> 9 <br /> work described above in accordance with the rules and regulations of San Joaquin County and subject to inspection and approval. <br /> 5/11/2014 <br /> CS9—Ignature of Applicant-Title Date <br /> E.PUB-SV.WKIMASTER.PSIENCROACNMENTPERMITAPPLICATION.DOC (01/08) <br />