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APPLICATION FOR ENCROACHMENT PERMIT <br /> PLEASE PRINT: <br /> Date 7/16/2015 OFFICE USE ONLY <br /> To: San Joaquin County JOB# Z REF# <br /> Department of Public Works APN CR# <br /> PG&E EXP.DATE - <br /> VALID TO - DRIVEWAYS: <br /> (Applicant Name) STREET <br /> 850 STILLWATER DR. TYPE QUAD _ <br /> (Mailing Address) FORMS <br /> WEST SACRAMENTO, CA 95605 NOTES <br /> (City,State,Zip Code) <br /> 3Z--)T,o01g0 <br /> (Area Code-Telephone Number) <br /> Sketch(Detailed plans may be submitted) <br /> inn, l X1 (2-� <br /> The undersigned hereby applies for permission to excavate,construct and/or otherwise encroach on County Highway Right-of-Way on <br /> the RIGHT side of MANILA RD approximately feet/mile <br /> of by performing the following work(description of work): <br /> REPLACE DETERIORATED POLE; MAKE MINOR EXCAVATION WITHIN COUNTY RIGHT-OF-WAYS <br /> EXCAVATION SHALL NOT EXCEED 35SQ FT IN AREA AND NOT GREATER THAN 6 LINEAR FT IN LENGTH <br /> Work will commence on or abouWs Vo Irv, qg <br /> r2CY for approximately 1-4 days. <br /> IOt <br /> I,the undersigned,certify that 1 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 /> 7/16/2015 <br /> Signature o Applicant-Title Date <br /> E?MI&SV.WKIMASTER.PSIPNCROACHMENTPERAAITAPPLICATION.DOC(01108) <br />