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APPLICATION FOR ENCROACHMENT PERMIT <br /> PLEASE PRINT: <br /> Date 7/9/2015 ^^�� OFFICE USE ONLY <br /> To: San Joaquin County JOB# �IZ REF# <br /> Department of Public Works APN CR# <br /> EXP.DATE �g/< <br /> PG&E VALID TO DRIVEWAYS: <br /> (Applicant Name) STREET <br /> 4040 WEST LN AREA .—QUAD <br /> TYPE kD <br /> (Mailing Address) FORMS S <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 submitted) <br /> SEE ATTACHED SKETCH <br /> PM 3116096 <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 FRENCH CAMP RD approximately 127' feet/mile SOUTH <br /> of ASH ST , FRENCH CAMP , by performing the following work(description of work): <br /> EXCAVATE(1)4'x4'BELLHOLE TO REPLACE GAS SERVICE TO 276 FRENCH CAMP RD <br /> Work will commence on or about 8/1/2015 for approximately 30 days. <br /> I,the undersigned,certify that I am-the­o`wner oM-e- pective property,or am qualified to represent the owner and agree to do the <br /> work described above'n-acc-o'rdance wit he eiv es and regulations of San Joaquin County and subject to inspection and approval. <br /> 7/8/2015 <br /> Signature of Applicant-Title Date <br /> E:TUB-SVWKWASTER.PSIENCROACHMENT PERMIT APPLICATION DOC (01/08) <br />