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APPLICATION FOR ENCROACHMENT PERMIT <br /> PLEASE PRINT: <br /> Date 4/6/2015 OFFICE USE ONLY <br /> To: San Joaquin County JOB# 73 b CS Z REF# <br /> Department of Public Works APN _ CR# <br /> EXP.DATE <br /> PG&E VALID 57-1 -15 TO (s DRIVEWAYS: <br /> (Applicant Name) STREET -f <br /> 4040 WEST LN AREA kt n QUAD ff <br /> TYPE l��11 A0/'0 <br /> (Mailing Address) FORMS <br /> STOCKTON, CA 95204 NOTES <br /> (City,State,Zip Code) <br /> 408-316-1767 <br /> (Area Code-Telephone Number) <br /> Sketch(Detailed plans may be submitted) <br /> SEE ATTACHED SKETCH <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 Princeton Ave approximately 297' feet/mile west <br /> of Kirk St Stockton _, by performing the following work(description of work): <br /> Excavate(1)4'x4'bellhole to replace gas service to 3044 Princeton Ave <br /> PM 31144912 <br /> Work will commence on or about 5/1/2015 _for approximately 30 days. <br /> I, the undersigned, i at I am the owner of the respective property,or am qualified to represent the owner and agree to do the <br /> work describe in accordance with the rules and regulations of San Joaquin County and subject to inspection and approval. <br /> 4/6/2015 <br /> Signa cant-Title Date <br /> EIPU&SV.WKMSTERPSIENGROACHMENT PERMIT APPLICATION.DOG (01/00) <br />