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APPLICATION FOR ENCROACHMENT PERMIT <br /> PLEASE PRINT: <br /> Date 04/09/2015 OFFICE USE ONLY <br /> To: San Joaquin County JOB# 7 62 REF# <br /> Department of Public Works APN CR# <br /> RICHARD KNIGHT EXP.DATE 9-- <br /> VALIDTO 'g-- /-15 DRIVEWAYS: <br /> (Applicant Name) STREET - <br /> sru lCJyl s' <br /> 850 Stillwater Rd AREA QUADTYPE ad�:'e <br /> (Mailing Address) FORMS SSS 2Z� <br /> West Sacramento, CA 95605 NOTES <br /> (City,State,Zip Code) <br /> 925-242-0454 <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 EAST side of S ESCALON BELLOTA RD approximately 460' feetlm+le NORTH <br /> of E SAN JULIEN RD FARMINGTON,CA ,by performing the following work(description of work): <br /> Replace Deteriorated Pole <br /> PM 31119251,Not: 109590428,Location 1 <br /> Work will commence on or about 07/10/2015 for approximately One <br /> 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 /> 04/09/2015 <br /> Signature of Applicant-Title Date <br /> M:ICENTRALSERVICESCLERICALnBZV.WKNASTER.PSIENCROACHMENTPEfA4FAPPLICATION.DOC (09113) <br />