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APPLICATION FOR ENCROACHMENT PERMIT $ P iso"ulf <br /> PLEASE PRINT: 2115 AUG 20 PM 3' 05 <br /> UP T. Of FUa IC WORKS- <br /> Date 08/14/2015 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 ~� t <br /> Estimator: Adam Vocrelaar VALID a IS' TO 2, Ito DRIVEWAYS: <br /> (Applicant Name) STREET 0-0Pb ;--, �p , <br /> Sacramento RMC AREA , J—,Z-J QUAD �.(( <br /> 850 Stillwater Rd TYPE -6144- <br /> (Mailing Address) FORMS w <br /> NOTES <br /> West_ Sacramento, CA 95605 <br /> (City,State,Zip Code) <br /> Est phone# : 925 . 327 . 0990 <br /> (Area Code-Telephone Number) <br /> Sketch (Detailed plans may be submitted) <br /> Pole Replacement <br /> PM 31139069 <br /> Notif: 110016075 <br /> Location: 10234 E.Copperopolis Rd 1/W, Stockton <br /> Construction drawing w/ dimensions, and TCP attached. <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 E.COPPEROPOLI S RD approximately 8 60 ' fenfe 'mile WEST <br /> of N. PATRICK RD STOCKTON by performing the following work(description of work): <br /> REPLACING EXISTING POLE. <br /> Work will commence on or about - 1 I 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 /> —' CONSULTING FIELD ENGINEER 08/14/2015 <br /> Signature of Applicant-Title Date <br /> M'',CEN?RA'—SERVICES.CLERICAL-'U6-SV6YTMASTEI.PSIENCRCAC:1'eIENT PERMIT APPUCATICN.DOC (09;1'x) <br />