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APPLICATION FOR ENCROACHMENT PERMIT <br /> PLEASE PRINT: <br /> Date 06/22/15 OFFICE USE ONLY <br /> To: San Joaquin County JOB# 1II T 7 )S2_t,�JREF# <br /> Department of Public Works APN �� CR# <br /> EXP.DATE c- / <br /> PACIFIC GAS & ELECTRIC VALID2�t DRIVEWAYS: <br /> 10 3l- t3i�" <br /> (Applicant Name) STREET W ku s 1 (0, <br /> AREA r QUAD til <br /> 850 STILLWATER DR TYPE oi <br /> (Mailing Address) FORMS 5 W 2 <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 /> PM# 31109425 - POLE LOCATION 1 <br /> I 3 <br /> The undersigned hereby applies for permission to excavate,construct and/or otherwise encroach on County Highway Right-of-Way on <br /> the SOUTH side of W UNDINE RD approximately 720 fee ile EAST <br /> of SWING LEVEE RD , STOCKTON ,by performing the following work(description of work): <br /> REPLACING EXISTING 50' WOOD POLE WITH NEW 50' WOOD POLE. NEW POLE WILL BE SET <br /> 1' SOUTHWEST OF EXISITNG POLE APPROXIMATELY 1' NORTH OF PROPERTY LINE <br /> (19' SOUTHWEST OF FOG LINE) <br /> Work will commence on or about for approximately 1 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 /> &ftj ^�J-J- CONSULTING FIELD ENGINEER 06/22/15 <br /> Signature of Applicant-Title Date <br /> M:ICENTRALSERVICESCLERICALIPURSV.WKIMASTER.PSIENCROACHMENT PERMIT APPLICATION.DOC (09H3) <br />