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APPLICATION FOR ENCROACHMENT PERMIT <br /> PLEASE PRINT: <br /> Date 4/21/2015 OFFICE USE ONLY <br /> To: San Joaquin County JOB# �3��z REF# <br /> Department of Public Works APN CR# <br /> EXP.DATE <br /> TONY LIN VALID /()-1S I S TO DRIVEWAYS: <br /> (Applicant Name) STREET uc <br /> AREA QUAD S� <br /> 850 STILLWATER DROVE TYPE /30f P <br /> (Mailing Address) FORMS 5 A Z!2 <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 /> The undersigned hereby applies for permission to excavate,construct and/or otherwise encroach on County Highway Right-of-Way on <br /> the KAISER ROAD side of E. MARIPOSA ROAD approximately 1,593.6 feet/mile FEET <br /> of , by performing the following work(description of work): <br /> REPLACE DETERIORATED POLE <br /> Work will commence on or about 10/23/2015 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 4-21-15 <br /> Signature of Applicant-Title Date <br /> M:ICENTRALSERVICESICLERICALIPUB-SV.WKVAASTERPSIENCROACHMENT PERMIT APPLICATION.DOC (09113) <br />