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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# t � x -� REF# <br /> Department of Public Works APN CR# <br /> EXP.DATE �� <br /> PG&E VALIDY TO (2 S.2a6 DRIVEWAYS: <br /> (Applicant Name) STREET � - v%Q <br /> 4040 WEST LN AREA QUAD <br /> TYPE � �p <br /> (Mailing Address) FORMS RZq,'Cr <br /> STOCKTON, CA 95204 NOTES f / <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 side of �,3L<Z Re. C AQL.- approximately :S�i ee ile --� <br /> of N�r 1-i ter AV <br /> <STOCKTON , by performing the following work(description of work): <br /> EXCAVATE(1)4'x4'BELLHOLE AT EACH LOCATION (5)TO REPLACE GAS SERVICE <br /> 4 -PIVI 3 1 15ar,61 <br /> 638 S Wagner Ave-PM 31158560 454 S MqP 0439- <br /> .543&-GaaPGW&6t--��893 <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 aec- r�with Vie:rules and regulations of San Joaquin County and subject to inspection and approval. <br /> y 7/7/2015 <br /> -'- Signature of Ap licant- itl Date <br /> E:IPUB-SV.WKWASTERPSIENCROACHMENTPERMTTAPPUCATION.DOC (01108) <br />