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APPLICATION FOR ENCROACHMENT PERMIT <br /> PLEASE PRINT: p5 - 1401 ( 41 <br /> Date 06-05-2014 I OFFICE USE ONLY <br /> To: San Joaquin County JOB# (( 000 5 REF# <br /> Department of Public Works APN CR# <br /> EXP.DATE 10—1 S - t <br /> C.O.S. Public Works Dept.: Attn: Rosa Alvarez VALID y-(- I ¢ TO to -If S-(¢ DRIVEWAYS: <br /> (Applicant Name) STREET 0 5* <br /> AREA 5+0C k46/1 QUAD <br /> 22 E. Weber Avenue, Room 301 TYPE ( f� <br /> (Mailing Address) FORMS S 5Z;dZ <br /> NOTES <br /> Stockton, CA 95202 <br /> (City,State, Zip Code) <br /> 209-937-8134 <br /> (Area Code-Telephone Number) <br /> Sketch(Detailed plans may be submitted) <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 B Street approximately 500 feet/mile <br /> of traffic Control by performing the following work(description of work): <br /> Install Traffic Control within the County right-of-way to allow the City to rehabilitate the existing sewer line at the Intersection of B <br /> Street and Ralph Avenue. <br /> Work will commence on or about September 2014 for approximately 45 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 /> r _ <br /> - Dl0 1 <br /> Signature of Appli an -Title date <br /> Rom ,alva%tz- <br /> (2at)cv;vi <br /> MICENTRALSERVICESICLERICALIPUB-SV.WNIMASTER.PSIENCROACHMENTPERMUAPPLICATION.DOC (09113) <br /> 1'UG,�'{.Q�VAY2��a �•�UG6V• Conn <br />