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APPLICATION FOR ENCROACHMENT PERMIT <br /> PLEASE PRINT: <br /> Date 10/2/2014 OFFICE USE ONLY <br /> To: San Joaquin County JOB# CC;S2- REF# <br /> Department of Public Works APN CR# <br /> EXP.DATE 5=20/S <br /> PG&E VALID (-1-20[ TO DRIVEWAYS: <br /> (Applicant Name) STREET <br /> 4040 WEST LN AREA 5�i[-C 6 QUAD <br /> \/ <br /> 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 42188014 <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 Broadridge Wy approximately various feet/mile <br /> of Stockton _, by performing the following work(description of work): <br /> Excavate(1) 5'x5'bellhole in front of 2312 Broadridge Wy&9812 Broadridge Wy to install cathodic <br /> protection anodes on existing steel gas main. Excavation will be behind curb. <br /> PM 42188013 <br /> Work will commence on or about \\ 1 for approximately 6n 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 Sari Joaquin County and subject to inspection and approval. <br /> II&AL 10/2/2014 <br /> ignature of Applicant-Title Date <br /> EIPUB-SV.WK%MASTER.PSIENCROACHMEFRPERMITAPPLICATION.DOC (0108) <br />