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APPLICATION FOR ENCROACHMENT PERMIT <br /> PLEASE PRINT: <br /> Date 1 OFFICE USE ONLY <br /> To: San Joaquin County JOB# 7 Or) s Z REF# <br /> Department of Public Works APN CR# <br /> Job Owner: Kimberly Van Fleet EXP.DATE !?^/ I S <br /> Estimator: Adam Voaelaar VALID -J- S TO - - /s' DRIVEWAYS: <br /> (Applicant Name) STREET ('�,,I-J3Pn�!- <br /> Sacramento RMC AREA T QUAD <br /> 850 Stillwater Rd TYPE <br /> (Mailing Address) FORMS , (dz 02,21! <br /> NOTES <br /> West Sacramento, CA 95605 <br /> (City,State,Zip Code) <br /> Est phone# : 925 . 327 . 0990 <br /> (Area Code-Telephone Number) <br /> Sketch (Detailed plans may be submitted) <br /> Pole Replacement <br /> PM 31109236 <br /> Notif: 108865698 <br /> Location: 4240 Carpenter Rd, Stockton <br /> Construction drawing attached. <br /> The undersigned hereby applies for permission to excavate, construct andlor otherwise encroach on County Highway Right-of-Way on <br /> the side of approximately feet/mile <br /> of by performing the following work(description of work): <br /> Work will commence on or about GAIIA 4 for approximately 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 /> AT��� S B l <br /> Signature of Applicant-Title Date <br /> M:ICENTRALSERACESICLERICALIPUE-SV.WK`.MASTER.PSIENCROACHVIENTPEWv11TAPPUCATION.DOC (0913) <br />