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PM: 31147597 <br /> Notification#: 110141767 APPLICATION FOR ENCROACHMENT PERMIT <br /> PLEASE PRINT: <br /> Date 07-30-2015 OFFICE USE ONLY <br /> To: San Joaquin County JOB# REF# <br /> Department of Public Works APN CR# <br /> Job Owner:Kimberly Van Fleet �• ( EXP. DATE <br /> Estisnatnr- W>»iam Escobar �, "� ` VALID 0 _(,S- (6' DRIVEWAYS: <br /> (Applicant Name) STREET 44 nd y_') <br /> AREA QUAD s ii✓ <br /> 850 Stillwater Drive TYPE <br /> (Mailing Address) FORMS <br /> NOTES <br /> West Sacramento, CA 95605 <br /> (City,State,Zip Code) <br /> 925-327-0990 <br /> (Area Code-Telephone Number) <br /> Sketch (Detailed plans may be submitted) <br /> Pole Replacement <br /> PM: 31147597 <br /> Noti£ 110141767 <br /> Location: 25000 BIRD RD 7PN <br /> Permit drawing and construction drawing included. Site does need TCP <br /> The undersigned hereby applies for permission to excavate,construct and/or otherwise encroach on County Highway Right-of-Way on <br /> the EAST side of BIRD RD. approximately 1/2 MI feet/mile SOUTH <br /> Of LO-VFL�'P-D , JR 4 Cv CA by performing the following work(description of work): <br /> Replacement of deteriorated electric(facility)wood pole <br /> Work will commence on or about 12-15-2015 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 in accordance with the rules and regulations of San Joaquin County and subject to inspection and approval. <br /> Estimating Engineer <br /> m_3n_7�5 <br /> Signature of Applicant-Title Date <br /> M10ENTRALSERVICESICLERICALIPUB-Sv.WKIMASTER.PSIENCROACHMENT PERMrr APPLICATION.00C (09113) <br />