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APPLICATION FOR ENCROACHMENT PERMIT <br /> PLEASE PRINT: <br /> Date 3/15/2015 OFFICE USE ONLY <br /> To: San Joaquin County JOB# 7 3040 S-2 REF# <br /> Department of Public Works APN CR# <br /> EXP. DATE -)S-/S <br /> TONY LIN VALID 7—Z3 )S TO 1,5 - DRIVEWAYS: <br /> (Applicant Name) STREET uY Sf <br /> AREA QUAD <br /> 850 STILLWATER DROVE TYPE <br /> (Mailing Address) FORMS <br /> NOTES <br /> WEST SACRAMENTO, CA 95605 <br /> (City, State,Zip Code) <br /> 925-327-0990 <br /> (Area Code-Telephone Number) <br /> Sketch (Detailed plans may be submitted) <br /> om <br /> t <br /> The undersigned hereby applies for permission to excavate,construct and/or otherwise encroach on County Highway Right-of-Way on <br /> the E. MAR-AST. side of S. SAINT WAILER LANE approximately 520 feeUmile FEET <br /> of by performing the following work(description of work): <br /> REPLACE DETERIORATED POLE <br /> Work will commence on or about 7/23/2015 for approximately 1 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 /> TONY LIN -CONSULTING FIELD ENGINEER II 3-11-15 <br /> Signature of Applicant-Title Date <br /> M.ICENTRALSERVICESICLERICALIPUBSV.WKUMSTER.PSIENCROACHMENT PERMIT APPLICATIONDOC (09113) <br />