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APPLICATION FOR ENCROACHMENT PERMIT <br /> PLEASE PRINT: <br /> Date JI 21 1s OFFICE USE ONLY <br /> To: San Joaquin County JOB# REF# <br /> Department of Public Works APN CR# <br /> // t EXP.DATE15 <br /> Nhan Ly -Gt51(- e6 � VALID DRIVEWAYS: <br /> (Applicant Name) STREET <br /> AREA QUAD _ <br /> 850 Stillwater Drive TYPE <br /> (Mailing Address) FORMS S141 W' P-2,9 <br /> NOTES <br /> West 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 /> Construction drawing is appended. Please refer to attachment. <br /> The undersigned hereby applies for permission to excavate,construct and/or otherwise encroach on County Highway Right-of-Way on <br /> the North side of E. Funck Rd. approximately 5,235' feet/mile West <br /> of S. Waverly Rd. / Hwy. 4 by performing the following work(description of work): <br /> Replacement of deteriorated electric(facility)wood pole <br /> Work will commence on or about_ for approximately 30 days. <br /> to to Z3 t Er <br /> I,the undersigned,certify that I am the ownbt 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 /> 6S7z}7 i5�p - Estimating Engineer 04-09-2015 <br /> Signature of Applicant-Title Date <br /> M1CENTRALSERVICES,CLERICALIPU&SV.VWAIASTER.PS%ENCROACHMENTPERMRAPPLICATION.U0C (09119) <br />