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APPLICATION FOR ENCROACHMENT PERMIT <br /> PLEASE PRINT: <br /> Date March 9,2015 OFFICE USE ONLY <br /> To: San Joaquin County JOB# j 1 a��' REF# <br /> Department of Public Works APN CR# <br /> EXP.DATE <br /> Verizon VALID _3 -31-1 S TO 5"- - S DRIVEWAYS: <br /> (Applicant Name) STREET LiA, (/ RG( <br /> AREA QUAD _ <br /> 201 Flynn Road TYPE <br /> (Mailing Address) FORMS 5 s k/ 2-T <br /> NOTES <br /> Camarillo,Ca. 93013 <br /> (City,State,Zip Code) <br /> 805-388-2266 <br /> (Area Code-Telephone Number) <br /> Sketch(Detailed plans may be submitted) <br /> Please see attached. Traffice Control Plan,and Substructure Work Plan.Verizon#4626-7P0A9WY <br /> The undersigned hereby applies for permission to excavate,construct and/or otherwise encroach on County Highway Right-of-Way on <br /> the side of approximately feet/mile <br /> of N.Wall Road and Highway 26 by performing the following work(description of work): <br /> _Relocation of existing Verizon buried facilities to remove existing structural conflicts with the County of San Joaquin Reconstruction_ <br /> Project of N.Wall Road. <br /> Work will commence on or about May 19 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 /> Digitally signed by Letitia Mattson <br /> Leticia DN:rn=Le6da Mattson,c US, <br /> email=LeWa.MaOsom@Cyientoom <br /> Reason:I am the author of this <br /> Mattsona`tte':2015.03.0909:20:22-OT00' March 9,2015 <br /> Signature of Applicant-Title Date <br /> td:10ENTRALSERNCESCLERICAL1PI18-SV.NMPMASTER.PSIENCROACHMENT PERMIT APPLICATION.DOC (09113) <br />