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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# 1Z REF# <br /> Department of Public Works A1PN QR# <br /> EXP.DATE I-/S-Zb/ <br /> PG&E VALID - 1--20l TO ^/S-2 ' DRIVEWAYS: <br /> (Applicant Name) STREET <br /> keA <br /> 4040 WEST LN AREA L QUAD ��ltiJ <br /> TYPE - <br /> (Mailing Address) FORMS - '5/i.J t'j, Q-2!q <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 42178808 <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 Palmquist Rd approximately 370' feet/mile east <br /> Of MaCarthur Dr , Tracy , by performing the following work(description of work): <br /> Excavate(1) 5'x5'bellhole to install cathodic protection anodes on existing gas main. <br /> PM 42178808 <br /> Work will commence on or about 11/1/2014 for approximately r)n 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 C46 10/2/2014 <br /> Signa ure of Applicant-Title Date <br /> E:IPUB.SV.WKVAASTER.PSIENCROACHLENTPERMITAPPLICATION.DOC (01/08) <br />