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APPLICATION FOR ENCROACHMENT PERMIT <br /> PLEASE PRINT: <br /> Date <br /> OFFICE USE ONLY <br /> To: San Joaquin County JOB# 7 3 06 SZ REF# <br /> Department of Public Works APN CR# <br /> EXP.DATE 6 "1.9 -I S <br /> PG&E VALID 4-3 - 1 S ,,TTOO ,�/ 1�s DRIVEWAYS: <br /> A <br /> (Applicant Name) STREET I<+!-k ►= <br /> AREA 5+0c QUAD <br /> 4040 WEST LN TYPE 6?&1 t h N jf <br /> (Mailing Address) FORMS _�� ►.i/(,�/ Z�_ <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 31087585 <br /> The undersigned hereby applies for permission to excavate,construct and/or otherwise encroach on County Highway Right-of-Way on <br /> the east side of Kirk Ave approximately 5' feet/mile north <br /> of W Mendocino Ave south p/I Stockton , by performing the following work(description of work): <br /> Excavate (1)4'x4' bellhole to replace gas service to 2900 Kirk Ave, Stockton <br /> PM 31087585 <br /> Work will commence on or about — S for approximately 60 days. <br /> I,the undersigned,certif t the owner of the respective property,or am qualified to represent the owner and agree to do the <br /> work described ab in a ance with the rules and regulations of San Joaquin County and subject to inspection and approval. <br /> (.ovva'„�s <br /> o pplicant-Title Date <br /> E:IPUMV.WKIMASTERPSIENCROACHMENTPERMITAPPLICATION.DOC (01108) <br />