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i <br /> APPLICATION FOR ENCROACHMENT PERMIT <br /> PLEASE PRINT: <br /> Date 10/2/2014 OFFICE USE ONLY <br /> To: San Joaquin County JOB# 7 Z-r6 REF# <br /> Department of Public Works APN CR# <br /> EXP.DATE /—/S—2�1.1- <br /> PG&E VALID b/y TO !—lS�2�Y DRIVEWAYS: <br /> (Applicant Name) STREET 5to -'C 1r <br /> 4040 WEST LN AREA QUAD <br /> TYPE <br /> (Mailing Address) FORMS SS/�r <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 42188011 <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 W Estate Dr approximately various feet/mile <br /> of Stockton _ by performing the following work(description of work): <br /> Excavate(1) 5'x5' bellhole in front of 2317 W Estate Dr, 2241 W E=state Dr, &2475 W Estate Dr to install cathodic <br /> protection anodes on existingsteel gas main. Excavation will be behind curb. <br /> PM 42188011 <br /> Work will commence on or about for approximately 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 /> ��- 10/2/2014 <br /> Signa ure of Applicant-Title Date <br /> E:IPUB-SVWKIMASTER.PSIENCROACHMENTPERMITAPPLICATION.DOC (01108) <br />