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APPLICATION FOR ENCROACHMENT PERMIT <br /> PLEASE PRINT: l �I C k 10 <br /> Date 10/27/2014 OFFICE USE ONLY <br /> To: San Joaquin County JOB# -7 3 0 REF# <br /> Department of Public Works APN CR# <br /> EXP. DATE �(� 5 <br /> PG&E VALID TO DRIVEWAYS: <br /> (Applicant Name) STREET <br /> 4040 WEST LN AREA �— QUAD <br /> TYPE <br /> (Mailing Address) FORMS � 4 Z <br /> STOCKTON, CA 95204 NOTES <br /> (City,State,Zip Code) <br /> 209-942-1421 <br /> (Area Code-Telephone Number) <br /> Sketch(Detailed plans may be submitted) <br /> SEE ATTACHED SKETCH <br /> PM 31023988 <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 Troy Ct& N Filbert St approximately feet/mile <br /> of , Stockton _, by performing the following work(description of work): <br /> Excavate (1)4'x6'tie in bellhole, (1)2'x2'daylight hole (4)4'x4'service bellholes, and bore 210'to replace existing gas main. <br /> Work will commence on or about 1/5/2014 for approximately 60 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 /> �)IL <br /> 10/27/2014 <br /> ignature of Applicant-Title Date <br /> E IPUB-SV.WKIMASTER.PSIENCROACHMENT PERMIT APPLICATION DOG (01108) <br />