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APPLICATION FOR ENCROACHMENT PERMIT <br /> PLEASE PRINT: <br /> 8/27/2014 OFFICE USE ONLY <br /> Date <br /> REF# <br /> To: San Joaquin County APN JOB# 7 CR# <br /> Department of Public Works <br /> EXP.DATE ( (�-� f 'j 4 DRIVEWAYS: <br /> PG&E VALID ��(7 -1 ¢ TO - <br /> (Applicant Name) STREET <br /> AREA QUAD __ <br /> 4040 WEST LN TYPE <br /> (Mailing Address) FORMS <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 42174244 <br /> The undersigned hereby applies for permission to excavate,construct and/or otherwise encroach on County Highway Rig <br /> i eht of Why on <br /> the West side of N Golfview Rd approximately <br /> of E Morse Rd , Lodi by performing the following work(description of work): <br /> Excavate(1)4'x4'bellhole for gas service maintenance. <br /> Work will commence on or about 9/22/2014 for approximately 30 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 /> 8/27/2014 <br /> Si re piicant-Title Date <br /> E:1PUB-SV MMASTER.PSTNCROACHMENT PERMIT APPLICATION.DOC(01108) <br />