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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# i ` �� REF# <br /> Department of Public Works APN CR# <br /> EXP.DATE l <br /> PG&E VALID ��^- )Z-�-TO L6'?-1S20 DRIVEWAYS: <br /> (Applicant Name) STREET <br /> 4040 WEST LN AREA TYPE �UAD <br /> (Mailing Address) FORMS LW&JU) Wq,1WAdAl ���/ <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 permission to excavate,construct and/or otherwise encroach on County Highway Right-of-Way on <br /> the c 54- side of AV 2 approximately 6;12- ' Qmile <br /> of STOCKTON , by performing the following work(description of work): <br /> EXCAVATE(1)4'x4' BELLHOLE AT EACH LOCATION (5)TO REPLACE GAS SERVICE <br /> 4Ag-S�da P*-8+458 & 443 S Sinclair Ave-PM 31158561 <br /> --RM 3958660 454 c gni qaa Ava PM-3 �L— <br /> M-3++64$93- <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 e rr ash a-Rules and regulations of San Joaquin County and subject to inspection and approval. <br /> 7/7/2015 <br /> Signature of Ap licant- itl Date <br /> E:IPU"V.WKPMSTER.PS%ENCROACHhENTPERMTAPPUCATION.DOC(01/08) <br />