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�16f/.1 / <br /> APPLICATION FOR ENCROACHMENT PERMIT <br /> PLEASE PRINT: <br /> Date 10/30/14 OFFICE USE ONLY <br /> To: San Joaquin County JOB# 5X561_G REF# <br /> Department of Public Works APN CR# <br /> EXP.DATE S 9 <br /> PG&E VALID 1,4 tO ////6 14 DRIVEWAYS: <br /> (Applicant Name) STREET coin <br /> AREA ,5&e1<46n QUAD <br /> 4040 West Ln. TYPE 6L An6e. 61.7ltrA,¢�A oivty� <br /> (Mailing Address) FORMS <br /> NOTES <br /> Stockton,CA 95204 F Al #ewer-1 6v ' <br /> (City,State,Zip Code) oak l.rait k-t ai` c o / el <br /> 11r %Ao4 block cr-f <br /> Sew F6*1GAti ''as- <br /> (Area Code-Telephone Number) <br /> Sketch (Detailed plans may be submitted) <br /> Detail of excavation location&traffic control plans attached <br /> M Z207��5 <br /> � l�TI'Al�lrc,e7 R�Q1191G �- Go�>+97'�D� <br /> The undersigned hereby applies for permission to excavate,construct and/or otherwise encroach on County Highway Right-of-Way on <br /> the�zi-1 ly side of X,or crT, approximately e—elmffe�AsT <br /> 0 !G E� <br /> Gas Service Replacement at 5804 E Acorn Ct. Work to be done in grass area(See Attached Google Maps Image). Excavation typically <br /> limited to 5'x 5'bell hole. <br /> of <br /> e�f <br /> Work will commence on or about 11LO12014 for approximately 2 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 /> 10/30/14 <br /> Signature of Applicant-Titl ate <br /> M.ICENTRALSERVICESICLERICALIPUB-SV.WKWASTER.PSIENCROACHMENT PERMIT APPLICATION.DOC (09/13) <br />