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APPLICATION FOR ENCROACHMENT PERMIT <br /> PLEASE PRINT: <br /> Date 2/4/2015 OFFICE USE ONLY <br /> To: San Joaquin County JOB# 73 N_C-2 _ - REF# <br /> Department of Public Works APN CR# <br /> PG&E EXP.DATE -_/- 20/5� <br /> VALID 3-1-tri/ 0 S—(- 2/� DRIVEWAYS: <br /> (Applicant Name) STREET C'_ ' <br /> 4040 WEST LN AREA .tv\ ev, QUAD <br /> TYPE <br /> (Mailing Address) FORMS SS���,, <br /> STOCKTON, CA 95204 NOTES <br /> (City,State,Zip Code) <br /> '2-0 /yi,i <br /> (Area Code-Telephone Number) <br /> Sketch(Detailed plans may be submitted) <br /> SEE ATTACHED SKETCH <br /> PM 42324175 <br /> The undersigned hereby applies for permission to excavate,construct and/or otherwise encroach on County Highway Right-of-Way on <br /> the WEST side of N COX RD approximately 1070' feet/mile NORTH <br /> of DI CARLO CT , LINDEN , by performing the following work(description of work): <br /> EXCAVATE (1) 4'x4' BELLHOLE TO REPAIR EXISTING GAS MAIN. <br /> Work will commence on or about 3/1/2015 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 /> 2/4/2015 <br /> ignature o Applicant-Title Date <br /> EVU&SVOKWASTERPSIENCROACHMENT PERMIT APPLICATIONAOC(01A8) <br />