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APPLICATION FOR ENCROACHMENT PERMIT <br /> PLEASE PRINT: <br /> Date OFFICE USE ONLY <br /> To: San Joaquin County JOB# '7�( �C,� REF# <br /> Department of Public Works APN CR# <br /> Job Owner: Kimberly Van Fleet �� EXP.DATE j <br /> Estimator: Adam Vogelaar / VALID TO _ DRIVEWAYS: <br /> (Applicant Name) STREET <br /> Sacramento RMC AREA _ QUAD <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 31119249 <br /> Notif: 109590427 <br /> Location: AC/F 4222 S.ESCALON BELLOTA, FARMINGTON, 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 Right-of-Way on <br /> the WEST sideof S ESCALON BELLOTA RD approximately 423 ' (efe mile NORTH <br /> of HIGHWAY 4 FARMINGTON by performing the following work(description of work): <br /> REPLACING EXISTING 45 ' POLE WITH NEW 45 ' POLE <br /> Work will commence on or about Uv <br /> for approximately days. <br /> l� 23 1 S <br /> I,the undersigned,certify that I am the ownlaF 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 /> �- CONSULTING FIELD ENGINEER 06/09/15 <br /> Signature of Applicant-Title Date <br /> MP,CEN?RASERNCESCtERICAU?UE-SV.VMIAAS'.ER.PMENCRCACHMENT PERMIT APPLICATIONDOC (09;13) <br />