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APPLICATION FOR ENCROACHMENT PERMIT <br /> PLEASE PRINT: <br /> Date 07/09/2015 OFFICE USE ONLY <br /> To: San Joaquin County JOB# 130057Z—j e REF# <br /> Department of Public Works APN _ CR# <br /> �,. EXP.DATEitlIIt <br /> '" <br /> MARCELINO SAMAGUEY VALID 0 11 11115- DRIVEWAYS: <br /> (Applicant Name) STREET 1U.t3 Rb. <br /> AREA "eacitt�G�.1 QUAD lq( <br /> 850 STILL WATER DR. TYPE 1Fp` 1 " <br /> (Mailing Address) FORMS :5zIta..O <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 /> PG&E WILL REPLACE A POLE,THERE WILL BE GROUND DISTURBANCE(DIGGING)2-3FT WIDE AND 7'DEEP.ATTACHED PLEASE <br /> FIND ASPECTS,CONSTRUCTION DRAWING AND IMAGES OF EXISTING POLE. <br /> PM:31139739 <br /> N OTI FICATIO N:110016068 <br /> CONDINATES(37.954201,-121.20395) <br /> The undersigned hereby applies for permission to excavate, construct and/or otherwise encroach on County Highway Right-of-Way on <br /> the ROAD side of 1563 GILLS RD SOCKTON CA 95215 approximately 0.4 <br /> Pp y feet/mile MI <br /> of CROSSING ST FARMINGTON RD , by performing the following work(description of work): <br /> REPLACE DETERIORATED POLE/PM 31139739 <br /> POLE LOCATED IN FRONT OF 1563 GILLIS RD STOCKTON CA 95215 <br /> Work will commence on or about 10/17/15 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 /> 07/09/2015 <br /> Signature of Applicant-Title Date <br /> hl'.10ENTRALSERVICES",CLERICAL''PU9SV'N,'NTASTER.POENCROACHMENTFER&ifTAPPLICATION.DOC (09/73) <br />