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APPLICATION FOR ENCROACHMENT PERMIT <br /> PLEASE PRINT: <br /> Date 12/18/14 OFFICE USE ONLY <br /> To: San Joaquin County JOB# � REF# <br /> Department of Public Works APN CR# <br /> EXP.DATE Q-/S-2_Cy/5 <br /> PG&E c/o Robert Lambert VALID I-2Z-Za15 DRIVEWAYS: <br /> (Applicant Name) STREET P_ (ZcA <br /> AREA QU <br /> L hrj,t � N VJ <br /> 5555 Florin Perkins Rd TYPE ���\1 <br /> (Mailing Address) FORMS SS/1 U V ) 2- <br /> NOTES NOTES <br /> Sacramento, CA 95826 <br /> (City,State,Zip Code) <br /> 916-386-5275 <br /> (Area Code-Telephone Number) <br /> Sketch(Detailed plans may be submitted) <br /> Please see attached construction drawings and traffic control plan. <br /> PM 31042579 <br /> The undersigned hereby applies for permission to excavate,construct and/or otherwise encroach on County Highway Right-of-Way on <br /> the South sideof W Woodbridge Rd approximately 4 .5 miles feet/mile West <br /> of Interstate 5 by performing the following work(description of work): <br /> On L-196A, retire 4,400 ' of 611 gas pipe. Work is mostly off of the <br /> right-of-way except for the bell hole in the shoulder of W Woodbridge Rd, <br /> for which a traffic control plan is provided. <br /> Work will commence on or about Jan-Apr, 2015 for approximately 2 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 /> 12/18/14 <br /> Simon ure of Applicant-Title Date <br /> E:IPUS SVWK MSTERPSIENCROACNMENTPERMITAPPUCATION DOC(01108) <br />