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PM: 31139054 r <br /> :I: <br /> Notification #: 110016087 APPLICATION FOR ENCROACHMENT PERMIT <br /> PLEASE PRINT: i <br /> DateOFFICE USE ONLY <br /> To: San Joaquin County JOB# 13-60:52--IT REF# <br /> Department of Public Works APN CR# <br /> EXP. DATE ItQ <br /> Nhan Ly :&r <br /> VALID to 2- k DRIVEWAYS: <br /> (Applicant Name) STREET <br /> 14) <br /> AREA L QUAD — <br /> 850 Stillwater Drive <br /> TYPE <br /> (Mailing Address) FORMS <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 /> Construction drawing is appended. Please refer to attachment. <br /> The undersigned hereby applies for permission to excavate,construct and/or otherwise encroach on County Highway Right-of-Way on <br /> the-Comer —side of E. Gawne Rd. &Van Allen Rd. approximately 725' feet/mile West <br /> of Van Allen Rd. I ,by performing the following work(description of—work), <br /> Replacement of deteriorated electric(facility)wood pole. <br /> Work will commence L-P for approximately <br /> days. <br /> 1,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 /> o`-71aw� - Estimating Engineer 07-30-2015 <br /> Signature of Applicant-Title Date <br /> MWENTRALSERIACES',GLERICALtPUB-SV.',VK11AASTERPSTNCROACHMENTPERtAfTAPPtICATION,DOC (0903) <br />