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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# tT,�'� x �� REF# <br /> Department of Public Works APN CR# <br /> EXP.DATES <br /> PG&E VALID TO DRIVEWAYS: <br /> (Applicant Name) STREET C' <br /> 4040 WEST LN AREA QUAD <br /> TYPE It V"A p <br /> (Mailing Address) FORMS L%lw i.ON I�C_A �j <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 side of t% N-OC— approximately (� I mile <br /> of 'QVE; STOCKTON , by performing the following work(description of work): <br /> EXCAVATE(1)4'x4' BELLHOLE AT EACH LOCATION(5)TO REPLACE GAS SERVICE. <br /> X0080 454 S Wagner Ave-PM 31158439 <br /> 3 <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)aec�nce with thexUles and regulations of San Joaquin County and subject to inspection and approval. <br /> 7/7/2015 <br /> +r Signature of Ap lip cant Title------- Date <br /> E:TUB-SV.WKIMASTER.PSIENCROACHMENTPERMrr APPLICATION.DOC(01108) <br />