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PM: 31119163 <br /> Notification#: 109590424 APPLICATION FOR ENCROACHMENT PERMIT <br /> PLEASE PRINT: <br /> Date 5' i LGI PS OFFICE USE ONLY <br /> To: San Joaquin County JOB# '73d� fZ REF# <br /> Department of Public Works APN CR# <br /> EXP. DATE g l <br /> Nhan Ly VALID 7-1(- <br /> �2-1S TO DRIVEWAYS: <br /> (Applicant Name) STREET &Yyve <br /> AREA L QUAD <br /> 850 Stillwater Drive TYPE diko * <br /> (Mailing Address) FORMS SS 2 Z9 <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 /> Construction drawing is appended. Please refer to attachment. <br /> The undersigned hereby applies for permission to excavate,construct and/or otherwise encroach on County Highway Right-of-Way on <br /> the Corner side of E. Grove Rd. &S. Escalon Bellota Rdapproximately 5' feet/mile East <br /> of S. Escalon Bellota Rd. ,by performing the following work(description of work): <br /> Replacement of deteriorated electric(facility)wood pole. <br /> Work will commence on or about 7-10-2015 for approximately 30 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 /> Estimating Engineer 04-09-2015 <br /> Signature of Applicant-Title Date <br /> M.kCENTRALSERVICES�CLERICALIPU&SV.WKIMASTER.PSIENCROACNMENTPERMITAPPLICATION.DOC (09113) <br />