Laserfiche WebLink
APPLICATION FOR ENCROACHMENT PERMIT <br /> PLEASE PRINT: <br /> Date 11/6/15 OFFICE USE ONLY <br /> To: San Joaquin County JOB# Q�,�, 3cj l-Z REF# <br /> Department of Public Works APN CR# <br /> EXP.DATE <br /> ---BIER-I20N OF CALI-FORN-IA --- — - - - <br /> VALID �- —2c''' TO - - 2 / DRIVEWAYS. <br /> (Applicant Name) STREET ;,,i,1 <br /> AREA L o6 __ QUAD <br /> 17855 COMCONEX RD TYPE 'e— C(ti <br /> (Mailing Address) FORMS ,�Zct <br /> MANTECA, CA 95336 NOTES <br /> (City,State,Zip Code) <br /> APPLICANT REP: KATHI STROUT <br /> 209 608-0655 <br /> (Area Code-Telephone Number) <br /> Sketch(Detailed plans may be submitted) <br /> Ref Verizon Work Order 4622 9PO15MS-001 <br /> See attached sketch. <br /> The undersigned hereby applies for permission to excavate, construct and/or otherwise encroach on County Highway Right-of-Way on <br /> the south side of Acampo Rd. approximately feet/mile east <br /> of N. Johnson Rd. - <br /> by performing the following work(description of work): <br /> Verizon proposes replacing an existing 2x3 splice box with a 2x3 box with <br /> traffic rated lid. Existing box is located in front of 22540 E. Acampo Rd. <br /> Clements . <br /> Work will commence on or about 11/30/15 for approximately 15 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 /> Signature of Applicant-Title Date <br /> E:IP(JMV.WKIMASTER.PSIENCROACHMENT PERMIT APPLICATION.DOC (01108) <br />