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APPLICATION FOR ENCROACHMENT PERMIT <br /> PLEASE PRINT: <br /> Date 4/16/15 OFFICE USE ONLY <br /> To: San Joaquin County JOB# 73005-Z_ REF# <br /> Department of Public Works APN CR# <br /> EXP.DATE 10 <br /> ADAM CHIN f4;Y(' i VALID gl-12-IS TO l Q-15-15 DRIVEWAYS: <br /> (Applicant Name) STREET j/enna I r S gal <br /> AREA 5 W850 STILLWATER RD. TYPEQUAD <br /> (Mailing Address) FORMS <br /> NOTES <br /> 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 High Right-of-Way on <br /> the SOUTH side of W VERNALIS RCS. approximately 2,122 fee ile WEST <br /> of S KOSTER RD. by performing the following work( cription of work): <br /> REPLACE DETERIORATED OVERHEAD ELECTRIC UTILITY POLE <br /> Work will commence on or about ! Is- 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 /> f k— 0�— 4/16/15 <br /> Si nature of Applicant-Title Date <br /> M:ICENTRALSERVICESCLERICALIPUBSV.VMV.IASTER.PSIENCROACM6IENTPERMRAPPLICATION.DOC (09%13) <br />