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APPLICATION FOR ENCROACHMENT PERMIT <br /> PLEASE PRINT: <br /> Date 7/8/2014 OFFICE USE ONLY <br /> To: San Joaquin County JOB# -7300 S2- REF# <br /> Department of Public Works [APN /� — CR# <br /> EXP.DATE ( -F" `� <br /> PG&E VALID 7^ZI-I`- TO `( ' DRIVEWAYS: <br /> (Applicant Name) STREET D p 1/r ►R S <br /> AREA L pd t QUAD__ <br /> 4040 WEST LN TYPE _ <br /> (Mailing Address) FORMS <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 42085260 <br /> The undersigned hereby applies for permission to excavate, construct and/or otherwise encroach on County Highway Right-RT ion <br /> EAST side of DEVRIES RD _approximately feet/mile <br /> the <br /> of WOODBRIDGE RD LODI by performing the following work(description of work): <br /> EXCAVATE 1)4'x4' BELLHOLE TO REPAIR GAS SERVICE TO 21112 DEVRIES RD, LODI <br /> Work will commence on or about for approximately 60 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 /> 7/8/2014 <br /> Signature o Applicant-Title Date <br /> E NUB-SV WKWASTERPSENCROACHMENT PERMIT APPLICATION.DOC (OV08) <br />