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PM: 31139864 <br /> Notification #: 110006855 APPLICATION FOR ENCROACHMENT PERMIT <br /> PLEASE PRINT: <br /> Date 09-15-2015 OFFICE USE ONLY <br /> To: San Joaquin County JOB# .J--.005-z- (a REF# <br /> Department of Public Works APN _ CR# <br /> Job Owner: Kimberly Van Fleet EXP. DATE Z � , <br /> Estimator- William Escobar VALID Ia M 1S- TO Z.—it-fl—I,- DRIVEWAYS: <br /> (Applicant Name) STREET OeA( 94. <br /> AREA Fpnml N-vTaZQUAD B 6 <br /> 850 Stillwater Drive TYPE FcAc <br /> (Mailing Address) FORMS 35�wu3 <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: 31139864 <br /> Notif: 110006855 <br /> Location: 6260 S. HENRY Rd, Farmington <br /> Permit drawing, Construction drawing attached <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 henry rd approximately 60' feet/mile south <br /> Of F. Snnora Rel by performing the following work(description of work): <br /> Replacement of deteriorated electric(facility)wood pole. <br /> Work will commence on or about z--1XVJy) 1a 13' 1 -- 1 'for approximately 30 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 /> lli�n�C mtb�r _ Estimating Engineer 09-15-2,015 <br /> Signature of Applicant-Title Date <br /> MtCENTRALSER'JICES',CLERICAL',PU&SV'A'K'.N!ASTER.PS'.ENCROACHNIENTPER;AITAPPLICATION.DOC (09113) <br />