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APPLICATION FOR ENCROACHMENT PERMIT <br /> PLEASE PRINT: <br /> Date 2/12/2015 OFFICE USE ONLY <br /> To: San Joaquin County JOB# p6 •, 26 REF# <br /> Department of Public Works APN CR# <br /> EXP.DATE <br /> PG&E VALID 2-f Z_2ai—TO DRIVEWAYS: <br /> (Applicant Name) STREET bijq- <br /> 4040 WEST LN AREA QUAD <br /> TYPE <br /> (Mailing Address) FORMSTIrQ� (kLy <br /> 2 <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 31134154 <br /> The undersigned hereby applies for permission to excavate,construct and/or otherwise encroach on County Highway Right-of-Way on <br /> the south side of E Miner Ave approximately 45' feet/mile west <br /> of Oro Ave , Stockton , by performing the following work(description of work): <br /> Excavate (1)4'x4' bellhole to lower existing gas service to clear San Joaquin County storm culvert installation. <br /> Work will commence on or about 2/17/2015 for approximately 4 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 /> 2/12/2015 <br /> gnature of Applicant-Title Date <br /> E:PUB-SVAKVAASTERPSIENCROACHMENT PERMIT APPLICATIONDOC(01108) <br />