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APPLICATION FOR ENCROACHMENT PERMIT <br /> 1 <br /> PLEASE PRINT: <br /> Date 10/30/14 OFFICE USE ONLY <br /> To: San Joaquin County JOB# 73o�$a_(o REF# <br /> Department of Public Works APN CR# <br /> EXP.DATE / oZ <br /> PG&E VALID 60 aTO f DRIVEWAYS: <br /> (Applicant Name) STREET 4Ae6D P6 c LD. <br /> AREA /1v0/ QUAD <br /> 4040 West Ln. TYPE Z _ U� /MOTES <br /> (Mailing Address) FORMS 34ww -Z <br /> NOTES <br /> Stockton,CA 95204 <br /> (City,State, Zip Code) <br /> (Area Cole-Telephone Number) <br /> Sketch (Detailed plans may be submitted) <br /> These locations have already had repairs completed. <br /> PIM-# .42-124 1G84 <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 repair excavation at locations. <br /> z- sEu,Uo��s -PAr� AP_,Ea <br /> Work will commence on or about loorlhw 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 ate <br /> M:10ENTRALSERVICESICLERICALIPUB-SV.WKIMASTER.PSIENCROACHMENTPERMITAPPLICATION.DOC (D9113) <br />