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SIlk iC =',u}iii' t,01iuriTy <br /> 2M AIG 21 Pet 1, 40 <br /> APPLICATION FOR ENCROACHMENT PERMIT <br /> PLEASE PRINT: DEPT, OF N,15LI. WORKS <br /> Date 8/13/15 <br /> To: San Joaquin County-Highway Department OFFICE USE ONLY <br /> JOB # 7z;' 06752 REF # <br /> PG&E ApN _ _ CRV# <br /> (Applicant Name) EXP. DATE <br /> � Z 'l -t5 <br /> 3185 M Street VALID10 -2_q-/STO 1 /4 S DRIVEWAYS: <br /> (Mailing Address) <br /> STREET <br /> S <br /> Merced, CA 95348 AREAE3-(,z i. QUADTYPE FORMS <br /> (City, State, Zip Code) NOTE <br /> 209-726-6367 <br /> (Area Code—Telephone Number) <br /> Sketch (Detailed plans may be submitted) <br /> PM# 3112 8949 <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/ e north of south property lin E: of;0428 Hall Road , by performing the following <br /> work: (description of work): PG&E to dig 4'x4' bell hole to install new gas service to <br /> 3042 Hall Road, Escalon. <br /> Work will commence on or about 8/31/2015 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 /> Z55�r__ 8/13/15 <br /> SIGNATURE OF APPLICANT—TITLE DATE <br />