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APPLICATION FOR ENCROACHMENT PERMIT <br /> PLEASE PRINT: <br /> Date 7/06/2015 OFFICE USE ONLY <br /> To: San Joaquin County JOB# 7 36 Q S Z REF# <br /> Department of Public Works APN CR# <br /> EXP.DATE: 13*-(S <br /> MARCELINOSAMAGUEY VALID [0-10-15 TO /l-(,S 1S DRIVEWAYS: <br /> (Applicant Name) T— STREET M-4 or-.n h v 101A <br /> AREA Ejcaj�. I bUAb SE <br /> 850 STILL WATER DR. TYPE c ' <br /> (Mailing Address) FORMS SSWW 22�! <br /> WEST SACRAMENTO,CA 95605 NOTES <br /> (City,State,Zip Code) <br /> 925-327-0990 <br /> (Area Code-Telephone Number) <br /> Sketch(Detailed plans may be submitted) <br /> PG&E WILL REPLACE A POLE,THERE WILL BE GROUND DISTURBANCE(DIGGING)2-3FT WIDE AND T DEEP.ATTACHED PLEASE <br /> FIND ASPECTS,CONSTRUCTION DRAWING AND IMAGES OF EXISTING POLE. <br /> PM:31140364 <br /> NOTI FICATION:109997439 <br /> CONDINATES(37.856768,-121.108972) <br /> The undersigned hereby applies for permission to excavate,construct and/or otherwise encroach on County Highway Right-of-Way ori <br /> the -RerAD 'M00side of 1195 MURPHY RD CA SOCKTON CA 95215 approximately 257 feet/mile_ /V <br /> of DODDS CROSSING RD _, by performing the following work(description of work): <br /> REPLACE DETERIORATED POLE/PM 311238:19 <br /> POLE LOCATED IN FRONT OF 1195 MURPWt RD STOCKTON CA 95215 <br /> Work will commence on or about 10/10/2015 for approximately 1-4 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 /> 7/06/2015 <br /> Signature of Applicant-Title Date <br /> M:ICENTRALSERVICESICLERICAL`PUBSV.WKMASTER.PSIENCROACHMENTPERMRAPPLICATION.DOC (09113) <br />