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"APPLICATION FOR ENCROACHMENT PERMIT <br /> PLEASE PRINT: <br /> Date 7-13-15 OFFICE USE ONLY <br /> To: San Joaquin County JOB 104- REF# <br /> Department of Public Works APN CR# <br /> EXP.DATE 9-11 -15 <br /> PG&E VALID 7-Z7-lS TO y_ (. 15 — DRIVEWAYS: <br /> (Applicant Name) STREET 14 4- T- <br /> 4040 WEST LN AREA S� QUAD <br /> TYPE <br /> (Mailing Address) FORMS <br /> STOCKTON,'CA 95204 NOTES <br /> (City, State,Zip Code) <br /> 408-316-1767 <br /> (Area Code-Telephone Number) <br /> Sketch(Detailed plans may be•subrrritted) <br /> SEE ATTACHED:DRAVUINGS&-FCP FOR 31154689 <br /> The undersigned hereby appiies for permission to-excavate-,construct and/or otherwise encroach on County Highway Right-of-Way on <br /> the All side of", Marine Ave.&"Telegraph Ave approximately (see notes below) feet/mile <br /> of _, by performing the following work(description of work): <br /> Relocate existing 2"Steel HP,gas main Iocated.within;Telegraph Ave (between Plymouth Rd& Delaware Ave) and existing <br /> 2" & 3"STL HP gas main segments,Within.Marine.Ave'(between La Jolla Dr&Alpine Ave) in order to clear SJ County road <br /> reconstruction "Country Club R-ea. onstructiorr Ph 2":Contact SJ County engineer Stephanie Kong (209-468-0380)for more <br /> information regarding SJ County project. Also,1 contact Stephanie Kong regarding restoration requirements for this work <br /> since the county will perform. inalpaving.subsequent to road reconstruction. <br /> Work will commence on or about- 7/27/15 _for approximately 30 days. <br /> I, the undersigned,certify that amt�.owneT o the respective property, or am qualified to represent the owner and agree to do the <br /> work described above i -- aofdance 'th-the rules and regulations of San Joaquin County and subject to inspection and approval. <br /> /3 /,j <br /> Signature of Applicant-Title o —"�""� Date <br /> E:NUB-SV.WKWASTER.PSIENCROACHMENT PERMIT APPLICATION.DDC(01/08) <br />