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APPLICATION FOR ENCROACHMENT PERMIT <br /> PLEASE PRINT: <br /> Date 10/30/14 OFFICE USE ONLY <br /> To: San Joaquin County JOB# 750511-4 REF# <br /> Department of Public Works APN CR# <br /> EXP.DATE // 9 <br /> PG&E VALID /0 0 I/y DRIVEWAYS: <br /> (Applicant Name) STREET IA . 75ko <br /> AREA Z QUAD <br /> 4040 West Ln. TYPE M S <br /> (Mailing Address) FORMS SS ww <br /> NOTES p , <br /> Stockton,CA 95204 <br /> (City,State,Zip Code) 45 <br /> (Area Co e-Telephone Number) <br /> Sketch (Detailed plans may be submitted) <br /> These locations have already had repairs completed. <br /> 217653'1 Lo&ewooD Ia. <br /> PfA#g2-174o5763 7AckTo�E (ZD. <br /> $E4 A7rge e-D / 1F:i%0 Gac gT9,,!,w <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 0locations. <br /> Z- �EIG �[1oIGE5 .- ',SIDEuJa9LK <br /> I- 6�tc, NatE - SNouta� �� <br /> Work will commence on or about 1 for approximately a? 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.ICENTRALSERVICEMCLERICALIPUB-SV.WKWASTER.PSIENCROACHMENTPERMrlAPPLICATION.DOC (09113) <br />