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S to ri j� .L l 1,l it t r 1 Y <br /> APPLICATION FOR ENCROACHMENT PERMIT 2114 AUG 21 PM- 1: 41 <br /> PLEASE PRINT: DEPT. OF F'b6L}G WOARKS <br /> Date 8/18/15 <br /> To: San Joaquin County-Highway Department OFFICE USE ONLY <br /> JOB / REF# <br /> PG&E APN - _ CRV# <br /> (Applicant Name) EXP. DATE_ Z-J <br /> 13 <br /> 3185 M Street VALID(0 TO l - I - 15 DRIVEWAYS: <br /> (Mailing Address) STREET !tri P:,rA <br /> AREA CS CGt l QUAD C <br /> Merced, CA 95348 TYPEFORMS <br /> �r- <br /> (City, State, Zip Code) NOTE <br /> 209-726-6367 <br /> (Area Code—Telephone Number) <br /> Sketch (Detailed plans may be submitted) <br /> PM# 3117 6515 <br /> Please see attached sketch <br /> The undersigned hereby applies for permission to excavate, construct and/or otherwise encroach on <br /> County Highway Right-of-Way on the South side of Hall Road approximately <br /> 4 feet/fie north of south property line of X0428 Hall Road , by performing the following <br /> work: (description of work): PG&E to dig 4'x4bell hole to cut off gas stub in front of <br /> 30428 Hall Road, Escalon. <br /> Work will commence on or about 8/31/x:015 for approximately 1 days. <br /> I the undersigned certify that I am the owner of the respective property, or am qualified to represent the <br /> owner agree to do the work described above in accordance with the rules, regulations of San Joaquin <br /> County and subject to inspection and approval. <br /> 8/18/15 <br /> SIGNATURE OF APPLICANT—TITLE DATE <br />