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APPLICATION FOR ENCROACHMENT PERMIT <br /> PLEASE PRINT: <br /> Date 10/5/2015 OFFICE USE ONLY <br /> To: San Joaquin County JOB# <br /> COS REF# <br /> Department of Public Works APN CR# <br /> EXP.DATE <br /> Tim Davis VALID - TO DRIVEWAYS: <br /> (Applicant Name) STREET +C. <br /> AREA <br /> 3043 Gold Canal Drive Suite 201 TYPE <br /> (Mailing Address) FORMS <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 West side of Gettysburg Place approximately 60 fee mile north <br /> of Benjamin Hold Drive by performing the following work( escription of work): <br /> Removal of SVE-011.SVMW-021 located in the street.The wells will be over-drilled and completely removed.Following overdrilling the well vault shall be removed <br /> as shown on the attached drawings. <br /> nr�{ 21� I( �- 36- SVMW oz� <br /> � --fy 1 (23,1 - Svh -o( ( <br /> Work will commence on or about 8/12/2015 for approximately 1 day for we]I removal and 1 day for vau It removal 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 /> EPUB-SV.WKIMASTER.PSIENCROACHMENT PERMIT APPLICATION DOC (01/08) <br />