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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>,`�i� x. REF# <br /> Department of Public Works APN CR# <br /> EXP.DATE t — --2� <br /> PG&E VALID —fir- TO DRIVEWAYS: <br /> (Applicant Name) STREET <br /> 4040 WEST LN AREA ti QUAD S <br /> TYPE <br /> (Mailing Address) FORMS :%/6OUj•(,Zq,'� <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 gn County Highway Right-of-Way on <br /> the� v�side of�. wX�� k -St <br /> STOCKTON approximately f.S �fe�t/mile <br /> of by performing the following work(description of work): <br /> EXCAVATE(1)4'x4' BELLHOLE AT EACH LOCATION (5)TO REPLACE GAS SERVICE <br /> 405 S Gertrude-PM 31158668 443 S Sinclair Ave-PM 31158561 <br /> 638 S Wagner Ave-PM 31158560 454 S Wagner Ave-PM 31158439 <br /> 5135 Carmellia St-PM 31164893 <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• rd�with(66.Mles and regulations of San Joaquin County and subject to inspection and approval. <br /> 7/7/2015 <br /> Signature of Ap lick ant-_,title Date <br /> E:1PUB-SV.WKIMASTER.PSIENCROACHMENTPERWTAPPIJCATION.DOC(0108) <br />