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APPLICATION FOR ENCROACHMENT PERMIT <br /> l <br /> PLEASE PRINT: <br /> Date 10/30/14 OFFICE USE ONLY <br /> To: San Joaquin County JOB# l p62'L REF# <br /> Department of Public Works APN CR# <br /> EXP.DATE i( 2 14 <br /> PG&E VALID io 131114 TO IIZ 14 DRIVEWAYS: <br /> (Applicant Name) STREET /1te ;abj i>, Ap <br /> AREA -5 t ,*i QUAD /1j6 <br /> 4040 West Ln. TYPE NI.L AfaI <br /> (Mailing Address) FORMS , <br /> NOTES <br /> Stockton,CA 95204 <br /> (City,State,Zip Code) R A, <br /> �ea,� �/ana�►ar� 9��39t�_,9S� w�P�� <br /> (Area Co&-Telephone Number) <br /> Sketch(Detailed plans may be submitted) <br /> These locations have already had repairs completed. <br /> 15!% AvAeN ID ��,0-1.49L Ala G4eATiaA) <br /> The undersigned hereby applies for permission to excavate,construct and/or otherwise encroach on County Highway Right-of-Way on <br /> the side of approximately feet/mile <br /> of by performing the following work(description of work): <br /> Proiect locations and paving for PG&E gas leak re air excavation at lflocationb. <br /> 140L* 'D(ar Tkou L r)GA <br /> T6 <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 /> 10/30/14 <br /> Signature of Applicant-Title Date <br /> M:ICENTRALSERVICESICLERICALIPUB-SV.WKVMSTER.PSIENCROACHMENTPERMIr APPLICATION DOC (09117) <br />