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APPLICATION FOR ENCROACHMENT PERMIT <br /> PLEASE PRINT: <br /> Date 06/15/2015 OFFICE USE ONLY <br /> To: San Joaquin County JOB# 7 300 REF# <br /> Department of Public Works APN CR# <br /> Job Owner: Kimberly Van Fleet EXP.DATE q-1 <br /> Estimator: Adam Vogelaar VALID TO Q-1 (S' DRIVEWAYS: <br /> (Applicant Name) STREET <br /> Sacramento RMC AREA QUAD 5 <br /> 850 Stillwater Rd TYPE <br /> (Mailing Address) FORMS <br /> NOTES <br /> West Sacramento, CA 95605 <br /> (City,State,Zip Code) <br /> Est phone# : 925 . 327 . 0990 <br /> (Area Code-Telephone Number) <br /> Sketch (Detailed plans may be submitted) <br /> Pole Replacement <br /> PM 31119072 <br /> Notif: 109590384 <br /> Location: 9651 AIRPORT WAY/8PN, STOCKTON, CA <br /> Permit drawing, Construction drawing, and TCP attached. <br /> The undersigned hereby applies for permission to excavate, construct and/or otherwise encroach on County Highway Ri ht-of-Way on <br /> the EAST sideof S AIRPORT WAY approximately 0 . 75 fe mile NORTH <br /> of FRENCH CAMP RD STOCKTON , by performing the following work(description of work): <br /> REPLACING EXISTING 40 ' POLE WITH NEW 451 POLE. <br /> Work will commence on or about for approximately 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 /> Q z—CONSULTING FIELD ENGINEER 06/15/2015 <br /> Signature of Applicant-Title Date <br /> M:ICENTRALSERNCES,CLERICALIPUBSV.WKV.IASTEP PSIENCROACHMENT PERMIT APPLICATION.DOC (09.13) <br />