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PM: 31139997 <br /> Notification#: 110006840 APPLICATION FOR ENCROACHMENT PERMIT <br /> 2M AUG 19 Ph 3: ! I <br /> PLEASE PRINT: <br /> ;LIC W0RKS <br /> Date 08-12-2015 OFFICE USE ONLY <br /> To: San Joaquin County JOB# 73005' _ REF# <br /> Department of Public Works APN CR# <br /> Job Owner: Kimberly Van Fleet 7 EXP.DATE -21, 1161 <br /> - sdmator- William -Escobar 1"� �" � VALID T �I JI: DRIVEWAYS: <br /> (Applicant Name) STREET P-2), <br /> AREA j%6w',d4.74A1QUAD /VF <br /> 850 Stillwater Drive TYPE Pe'l*_ PLAT�IYIE `i ' <br /> (Mailing Address) FORMS S5 Lytes <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: 31139997 <br /> Notif: 110006840 <br /> Location: 6577 S. Escalon Bellota Rd, Farmington <br /> Permit drawing, Construction drawing <br /> The undersigned hereby applies for permission to excavate,construct and/or otherwise encroach on County Highway Right-of-Way on <br /> the West side of S. Escalon Bellota Rd approximately 1.6mi feet/mile south <br /> of CA-4 Highway(farmington rd.) Farmington by performing the following work(description of work): <br /> Replacement of deteriorated electric(facility)wood pole <br /> Work will commence on or about LIM0 K 1 P? Z5 for approximately 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 /> CVl 1111-,u C-Z-71a,�b- - Estimating Engineer 8-12-2015 <br /> Signature of Applicant-Title Date <br /> M.�CENTRALSERVICES',CLERICAL'.PUB SV.'A'Kl!iASTER.PS`.ENCROACHMENTPERMrr APPLICATION DOC (0913) <br />