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APPLICATION FOR ENCROACHMENT PERMIT <br /> PLEASE PRINT: <br /> Date 1015!2015 OFFICE USE ONLY <br /> To: San Joaquin County JOB# 9-0REF# <br /> Department of Public Works APN CR# <br /> EXP.DATE <br /> Tim Davis VALID p ZO TO DRIVEWAYS: <br /> ^�-Z'� <br /> (Applicant Name) STREET <br /> AREA—QUAD <br /> 3043 Gold Canal Drive Suite 201 TYPE <br /> (Mailing Address) FORMS �c „ w,� <br /> NOTES <br /> Rancho Cordova,CA <br /> (City,State,Zip Code) <br /> 916-637-8334 <br /> (Area Code-Telephone Number) <br /> Sketch (Detailed plans may be submitted) <br /> See Attached <br /> The undersigned hereby applies for permission to excavate,construct and/or otherwise encroach on County Highway Right-of-Way on <br /> the North Side side of Benjamin Holt Drive approximately 50 (fee pile east <br /> of Gettysburg Place , , by performing the following work(description of work): <br /> Removal of SVE-013.SV-013 is located in the sidewalk.The well will be over-drilled and completely removed.Following overdrilling the well vault shall be removed <br /> as shown on the attached drawings. <br /> -,,,A y ISI 123 - svF-�t 3 <br /> Work will commence on or about 8n2i201a for approximately fi0 I ofc l wIo ( CIL-4 C'.'&-. 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 /> 10/5/2015 <br /> Signature of Applicant-Title Date <br /> E IPUB-SV.WKWASTER.PSIENCROACHMENT PERMIT APPLICATION.DOC(011D8) <br />