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PM: 31139868 <br />Notification#: 110006851 APPLICATION FOR ENCROACHMENT PERMIT <br />PLEASE PRINT: <br />Date 07-10-2015 OFFICE USE ONLY <br />To: San Joaquin County JOB# REF# <br />Department of Public Works APN CR# <br />William Escobar <br />EXP.DATE <br />13-1 TO DRIVEWAYS: <br />Applicant Name) STREET <br />AREA L C4 QUAD <br />850 Stillwater Drive TYPE 1. P <br />Mailing Address) FORMS <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: 31139868 <br />Notif 110006851 <br />Location: 4767 Escalon Bellota RD 1P S <br />Permit Drawing and Construction drawing attached <br />The undersigned hereby applies for permission to excavate,construct and/or otherwise encroach on County Highway Right-of-Way onthewestsideofEscalonBellotaRDapproximately1/4 mi feet/mile South <br />of CA-4 Highway Farmington Ca ,by performing the following work(description of work): <br />Replacement of deteriorated electric(facility)wood pole <br />Work will commence on or about 10-13-2015 for approximately 30 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 />Grllinir C,uscabar - Estimating Engineer 07-10-2015 <br />Signature of Applicant-Title Date <br />M10ENTRALSERVICESICLERICALIPU&SV.WKM4STER.PS\ENCROACHMENTPERMRPPPLICATION.DOC (09113)