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APPLICATION FOR ENCROACHMENT PERMIT <br /> PLEASE PRINT: <br /> Date 3/23/2015 OFFICE USE ONLY <br /> To: San Joaquin County JOB# REF# <br /> Department of Public Works APN CR# <br /> EXP.DATE <br /> PG&E VALID 15- DRIVEWAYS: <br /> (Applicant Name) STREET <br /> AREAST -0 QUAD L <br /> 4040 WEST LN TYPE �S.pM"Acs <br /> (Mailing Address) FORMSSS�j,j 1�'2� TYPwE��f <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 /> m a <br /> SEE ATTACHED SKETCH <br /> a • <br /> The undersigned hereby applies for permission to excavate,construct and/or otherwise encroach on County Highway Right-of-Way on <br /> the both side of La Jolla Ave approximately feet/mile <br /> of Multiple Locations , Stockton , by performing the following work(description of work): <br /> Excavate (1) 3'x3'bellhole e/o Hogue Ave, (2) 3'x3' bellhole e/o Dennis Ave, (2) 3'x3' pot holes e/o Delaware Ave, <br /> (2) 3'x3' pot holes e/o Nina Ave, and (2) 3'x3' pot holes e/o Marine Ave, Stockton. These pot holes are in support of <br /> San Joaquin County's East Country Club Reconstruction Project. <br /> PM 42355069 <br /> Work will commence on or about 3/26/2015 for approximately 10 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 /> C �a'L'- <br /> 3/23/2015 <br /> Sign tur of Applicant-Title Date <br /> E:IPUSSV.WKWASTER.PSIENCROACHMENT PERMIT APPLICATION.DOC (01108) <br />