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APPLICATION FOR ENCROACHMENT PERMIT <br /> PLEASE PRINT: <br /> Date 9/5/2014 OFFICE USE ONLY <br /> To: San Joaquin County JOB# -73003-2 REF# <br /> Department of Public Works APN CR# <br /> EXP.DATE ((l—� [-(4 <br /> PG&E VALID ?-( TO _�(�-3(-( ¢ DRIVEWAYS: <br /> (Applicant Name) STREET 411 <br /> 4040 WEST LN AREA � QUAD 5 C <br /> TYPE <br /> (Mailing Address) FORMSS S/!�/11/ <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 <br /> PM 30999934 <br /> The undersigned hereby applies for permission to excavate,construct and/or otherwise encroach on County Highway Right-of-Way on <br /> the S side of W YOSEMITE AVE approximately 5201 feet/mile E <br /> of MCKINLEY AVE MANTECA , by performing the following work(description of work): <br /> EXCAVATE (1) 4 'x4 ' BELLHOLE TO CUT OFF EXISTING GAS SERVICE. EXCAVATE (1) <br /> 4 'x4 ' BELLHOLE AND TRENCH 15 ' TO INSTALL NEW GAS SERVICE TO 2900 W YOSEMITE <br /> AVE. <br /> Work will commence on or about 10/1/2014 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 /> work described above in accordance with the rules and regulations of San Joaquin County and subject to inspection and approval. <br /> (I--C� gz /� <br /> Signature of Applicant-Title Date <br /> E:NUB-SV WKIMASTER PSIENCR-CNMENT PERMIT APPLICATION.DOC (01106) <br />