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APPLICATION FOR ENCROACHMENT PERMIT <br />PLEASE PRINT: <br />Date <br />To: <br />FEBRUARY 4,2016 <br />San Joaquin County <br />Departmentof Public Works <br />PG&E <br />(Applicant Name) <br />4040 WEST LN <br />(Mailing Address) <br />STOCKTON,CA 95204 <br />(City,State,Zip Code) <br />408-316-1767 <br />(Area Code.Telephone Number) <br />J08# <br />APN <br />EXP.DATE <br />VALID <br />STREET <br />AREA <br />TYPE <br />FORMS <br />NOTES <br />OFFICE USE ONLY <br />REF# <br />CR# <br />DRIVEWAYS: <br />Sketch (Detailed plans may be submitted) <br />SEE ATIACHED SKETCH <br />The undersigned hereby appliesfor permissionto excavate,construct and/or otherwise encroach on County Highway Right-of-Way on <br />the SOUTH side of CLEMENT AVE approximately 273'feeUmile WEST <br />of N.WISCONSIN AVE STOCKTON,by performingthefollowing work (description of work): <br />EXCAVATE (1)4'x4'BELLHOLE TO REPLACE EXISTING GAS SERVICE TO <br />3445 CLEMENT AVE <br />PM 31215483 <br />Work will commence on or about MARCH 1,2 °16 for approximately -=6"'O days. <br />I,the undersigned,certify that I am the owner of the respective property,or am qualified to representthe owner and agree to do the <br />work described above in accordancewith the rules and regulations of San Joaquin County and subject to inspection and approval. <br />.f'GE gJ-1~""",,~'._ <br />Signature of Applicant-Title <br />2-.7-::::w {6' <br />FEB 4,2016 <br />Date