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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# 13.0 REF# <br /> Department of Public Works APN CR# <br /> EXP.DATE Z <br /> PG&E VALID 0 14 T JJ Z — DRIVEWAYS: <br /> (Applicant Name) STREET Nlu ,'p1e LDcorlb -t <br /> AREA MOM& QUAD <br /> 4040 West Ln. TYPE t-L E{p1:ES <br /> (Mailing Address) FORMS 5 ww, 9-29. 4lr 6-e, a i, <br /> NOTES <br /> Stockton,CA 95204 <br /> (City,State,Zip Code) <br /> � Y <br /> Jrea,l j/ana ars <br /> (Area Cole-Telephone Number) <br /> Sketch(Detailed plans may be submitted) <br /> These locations have already had repairs completed. <br /> IM#-Ii 22v1S1-7 47.5 NPd. <br /> PMS ,4ZZ(Z31-'Z- �480� N i 10► 5 lid.) <br /> P q 'Z.IoCole Dr.) <br /> PM:' IZZols-r? (4838 Morc,90- L-6) <br /> �Mst �}ZZot4o1 (qUo Cole Dc.) <br /> /jW";9 4S <br /> 56e A77 - 404 ZAOC t inNS <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 ato locations. <br /> 3- iia...�-161rc3 �►s. D i ALT' SlaatsL.o4.4L <br /> 2-"�tt.a-la�E.s t tit PIAJ� A�feA <br /> Work will commence on or about 10121111-4 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.WKIMASTER.PSIENCROACHMENT PERMIT APPLICATION DOC (09113) <br />