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APPLICATION FOR ENCROACHMENT PERMIT <br /> PLEASE PRINT: <br /> Date 12-01-14 OFFICE USE ONLY <br /> To: San Joaquin County JOB# 7 3 CJ 0 REF# <br /> Department of Public Works APN CR# <br /> EXP.DATE 6-/ <br /> PG&E (Ed Arroyo VALID - TO C -I- <br /> _t,57 DRIVEWAYS <br /> (Applicant Name) STREET <br /> AREA QUAD _ �/ <br /> 850 Stillwater Rd 1.5 <br /> TYPE ,C <br /> (Mailing Address) FORMS g/it/W 2q <br /> NOTES <br /> West Sacramento, Ca 95605 <br /> (City, State,zip code) <br /> 916-760-1945 <br /> (Area Code-Telephone Number) <br /> Sketch(Detailed plans may be submitted) <br /> location 5. Replace pole <br /> The crews will drill one hole on the S/E corner of Harding Way & <br /> Newport Ave. <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 feeYmile <br /> Of by performing the following work(description of work): <br /> This location is not on the Hwy. <br /> Work will commence on or about-)-I M1 - 4 I for approximately days, <br /> i <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 /> 1-2-01-14 <br /> Signature of ' licant-Title Date <br /> M!CENT RALSEW(1_S1CLFr1r;LPU8Sv%VMRSTER MNCRQ4fWFif PERMIT APPUCA�ON DOC 10993) <br />