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PM: 31119066 <br /> Notification#: 109590379 APPLICATION FOR ENCROACHMENT PERMIT <br /> PLEASE PRINT: <br /> Date 07-27-2015 OFFICE USE ONLY <br /> To: San Joaquin County [PN <br /> �0 5 2 REF# <br /> Department of Public Works <br /> CR# <br /> Nhan Ly ATE � �S(Applicant Name) TTO - DRIVEWAYS: <br /> t <br /> 850 Stillwater Drive AREA QUA <br /> TYPE <br /> (Mailing Address) FORMS � <br /> West Sacramento CA 95605 NOTES <br /> (City,State,Zip Code) <br /> 925-327-0990 <br /> (Area Code-Telephone Number) <br /> Sketch(Detailed plans may be submitted) <br /> Construction drawing is appended. Please refer to attachment. <br /> The undersigned hereby applies for permission to excavate,construct and/or otherwise encroach on County Highway Right-of-Way on <br /> the Corner Side Of Jack Tone Rd./Lone Tree Rd./French Cam Rd. , <br /> Of Jack Tone Rd.&Lone Tree Rd. P approximately 4,150 feet/mile N/W <br /> ,by performing the following work(description ofow�rk): <br /> Replacement of deteriorated electric(facility)wood pole. <br /> Work will commence on or about 10-22-2015 <br /> 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 /> c'71a - Estimating Engineer <br /> Signature of Applicant-Title 07-27-2015 <br /> Date <br /> MICE"RAL'ERV'CES'CLEPoCAL1Pu&SV.M(,A-WSTER.PSIEWROACHMENTPERMrf APPLICAT10N.00C (OV3) <br />