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APPLICATION FOR ENCROACHMENT PERMIT <br /> PLEASE PRINT: <br /> Date December 9, 2014 OFFICE USE ONLY <br /> To: San Joaquin County JOB# 110005 REF# <br /> Department of Public Works APN CR# <br /> East Bay Municipal Utility District(EBMUD) EXP.DATE <br /> VALID TO [-[ - [{ DRIVEWAYS: <br /> (Applicant Name) STREET101 Ic rt <br /> 1804 W. Main Street AREA _0ClcefOrd QUAD Al <br /> TYPE T C P <br /> (Mailing Address) FORMS SZJAI U/ <br /> Stockton, CA 95203 NOTES <br /> (City,State,Zip Code) <br /> 209-946-8007 <br /> (Area Code-Telephone Number) <br /> Sketch(Detailed plans may be submitted) See attached plans <br /> The undersigned hereby applies for permission to excavate,construct and/or otherwise encroach on County Highway Right-of-Way on <br /> the vanous side of various approximately various feet/mile various <br /> Of , by performing the following work(description of work): <br /> East Bay Municipal Utility District(EBMUD)operates a 72-inch raw water transmission pipeline from Clay Station Road <br /> to Cord Road.terminating at the EBMUD Mokelumne Aqueducts. On a periodic and/or emergency basis. EBMUD will <br /> perform operations and maintenance, inspections and monitoring of pipeline appurtenances such as valves. EBMUD <br /> staff will need access to vaults and other appurtenances along various roads and road shoulders. <br /> Work will commence on or about various for approximately 1 hour-5 days 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 /> ikwa� Irtl" U r 2 /,I- `//- Zo <br /> Signat a of Applicant-Title Date <br /> M]CENTRALSERVICEMCLERICALIPUBSV.WKIMASTER.PMENCROACHMENT PERMIT APPLICATION.DOC (09113) <br />