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PM: 31139866 <br /> Notification#: 110006853 APPLICATION FOR ENCROACHMENT PERMIT <br /> PLEASE PRINT: ` <br /> Date A61 15/ OFFICE USE ONLY <br /> To: San Joaquin County JOB# 73Od REF# <br /> Department of Public Works APN CR# <br /> Job Owner:Kimberly Van Fleet tiEXP.DATE: -1 5 - <br /> FctiTnatnT• Wil iamEscohar ��� VALID 1 -zfi -�6 TO Z-(, -16 DRIVEWAYS: <br /> (Applicant Name) STREET <br /> �n �� AREA i�nrfil F NQUAD <br /> 850 Stillwater- Z`-- TYPE h 4 f <br /> (Mailing Address) FORMS JL4/ P 2� <br /> NOTES <br /> __West Sacramento, CA 95605 <br /> (City,State,Zip Code) <br /> 925-327-0990 <br /> (Area Code-Telephone Number) <br /> Sketch(Detailed plans may be submitted) <br /> Pole Replacement <br /> PM: 31139866 <br /> Notif: 110006853 <br /> Location: N/E EO IST&ELM ST 1P N <br /> Permit drawing, Construction drawing <br /> The undersigned hereby applies for permission to excavate,construct and/or otherwise encroach on County Highway Right-of-Way on <br /> the EAST side of S 1ST ST approximately 30' feet/mile NORTH <br /> of ELM ST. , _, by performing the following work(description of work): <br /> Replacement of deteriorated electric(facility)wood pole. <br /> Work will commence on or about I ,9--Ui_f Z-0 —for approximately days. <br /> I <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 /> 0�111irnr(9-'Mbsr - Estimating Engineer _ 10-140(115 <br /> Signature of Applicant-Title Date <br /> M:ICENTRALSERVICESICLERICALIPOS-SV.WKIMASTER.PSIENCROACHMENTPERMITAPPLKIATION.DOC (09/13) <br />