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PickU p APPLICATION FOR ENCROACHMENT PERMIT <br /> PLt=ASE PRINT <br /> Date 9/8/2015 OFFICE USE ONLY <br /> To: San Joaquin County JOB# 7 3 ()7 q REF# <br /> Department of Public Works APN CR# <br /> EXP.DATE 3: -1-1 <br /> Modesta Jacquez VALID 1q .2-1- TO 3-J-1,6 DRIVEWAYS: <br /> (Applicant Name) STREET6121 Bollinger Canyan Rd., BR1Z4D AREA 4U 41TYPE adr_o: <br /> (Mailing Address) FORMS SS WA,-- /T Z� <br /> San Ramon, CA 94583 NOTES <br /> (City,State,Zip Code) <br /> 925-244-3813 <br /> (Area Code-Telephone Number) <br /> Sketch(Detailed plans may be submitted) <br /> SEE ATTACHMENTS <br /> The undersigned hereby applies for permission to excavate,construct and/or otherwise encroach on County Highway Right-of-Way on <br /> the side of approximately feet/mile <br /> of various locations along Armstrong Rd and Harney Ln by performing the following work(description of work); <br /> Utility excavation and traffic control for PG&E gas line work. <br /> Work will commence on or about September 2015 for approximately February 2016 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 /> 9/8/20115 <br /> Signature of A p - i e Date <br /> IA.10EHTRALSER4ICES,CLERICALIPL•3-SVa+JF„J•.STEH.PS',EFICROACHI•.{ENTP-RIJITAPPLICA?IaN.DOZ;(79113) <br />