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APPLICATION FOR ENCROACHMENT PERMIT <br /> PLEASE PRINT: <br /> Date 9/30/2014 OFFICE USE ONLY <br /> To: San Joaquin County JOB# _ REF# <br /> Department of Public Works APN CR# <br /> PG&E EXP.DATE <br /> VALID /./_ 2oi y TO DRIVEWAYS: <br /> (Applicant Name) STREET f,J�� �- k"_N/ <br /> 4040 WEST LN AREA _S rnCV_4-m -QUAD <br /> TYPE t4v"p l,"P_ <br /> (Mailing Address) FORMS S511i AVJLza <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 SKETC ° � 24/ ',f' " <br /> PM 31097691 <br /> The undersigned hereby applies for permission to excavate, construct and/or otherwise encroach on County Highway Right-of-Way on <br /> the West side of N Wilsons _ approximately 860' north <br /> _________ PP Y feet/mile <br /> of McAllen Rd Stockton by performing the following work(description of work): <br /> Excavate (1)4'x4'bellhole to replace gas service to 4545 N Wilson Wy, Stockton <br /> PM 31097691 <br /> Work will commence on or about 11/1/2014 for approximately 60 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 ��v __ 9/30/2014 <br /> t e of Applicant-Title Date <br /> E.IPUB-SV.WKIMASTER.PSIENCROACHMENT PERMIT APPLICATION DOC (01108) <br />