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APPLICATION FOR ENCROACHMENT PERMIT <br /> PLEASE PRINT: <br /> Date 7/7/2015 OFFICE USE ONLY <br /> To: San Joaquin County JOB# �_ �n,�` x REF# <br /> Department of Public Works APN CR# <br /> EXP.DATE t <br /> PG&E VALID - TO DRIVEWAYS: <br /> (Applicant Name) STREETAREA t QUAD .y <br /> 4040 WEST LN - <br /> i TYPE <br /> 1 <br /> (Mailing Address) FORMS :5S/(t)w,eZq, � 1,C <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 /> The undersigned hereby applies for permissio to excavate,construct and/or otherwise encroach gn County Highway Right-of-Way on <br /> the Cf.�t side of � i3�-- , approximately1 r fee <br /> of S STOCKTON by performing the following work( eption of work): <br /> EXCAVATE(1)4'x4' BELLHOLE AT EACH OCATION (5)TO REPLACE GAS SERVICE <br /> 405 SGertrude-PM 31158668 <br /> 1 <br /> 5 <br /> Work will commence on or about 8/1/2015 for approximately 30 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 i ae ounce with the:rules and regulations of San Joaquin County and subject to inspection and approval. <br /> 7/7/2015 <br /> Signature of Ap licant-'title---- Date <br /> E?PUB-SV.WKUAASTER.PSIENCROACHMENT PERMIT APPLICATIONDOC (01108) <br />