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APPLICATION FOR ENCROACHMENT PERMIT <br /> PLEASE PRINT: <br /> Date 6/25/2015 OFFICE USE ONLY <br /> To: San Joaquin County JOB# 73D P15' REF# <br /> Department of Public Works APN _ CR# <br /> PG&E EXP,DATE <br /> VALID DRIVEWAYS: <br /> (Applicant Name) STREET [100rA S� <br /> 850 STILLWATER DR. AREA 1 �j1- Q1'1 QUAD x <br /> TYPE are <br /> (Mailing Address) FORMS <br /> WEST SACRAMENTO, CA 95605 NOTES <br /> (City,State,Zip Code) <br /> r~G�2S� 3)--I- 0C1q 'l ._ S cm (jm <br /> (Area Code-Telephone Number) <br /> Sketch(Detailed plans may be submitted) <br /> mtv 3fl�O 3jCo <br /> The undersigned hereby applies for permission to excavate,construct and/or otherwise encroach on County Highway Right-of-Way on <br /> the RIGHT side of EL DORADO ST. approximately feet/mile <br /> of ,by performing the following work(description of work): <br /> REPLACE DETERIORATED POLE; MAKE MINOR EXCAVATION WITHIN COUNTY RIGHT-OF-WAYS <br /> EXCAVATION SHALL NOT EXCEED 35SQ FT IN AREA AND NOT GREATER THAN 6 LINEAR FT IN LENGTH <br /> Work will commence on or about 10/10/2015 for approximately 1-4 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 /> 6/25/2015 <br /> Signature o Applicant-Title Date <br /> E:1PUMV.NRIMASTER.PSIENCROACHMENTPERMITAPPLICATION.DOC (01108) <br />