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PM: 31162235 <br />Notification#: 110283208 APPLICATION FOR ENCROACHMENT PERMIT <br />PLEASE PRINT: <br />Date 10-02-2015 OFFICE USE ONLY <br />To: San Joaquin County JOB# 7—,SZ REF# <br />Department of Public Works APN CR# <br />Job Owner: Kimberly Van Fleet EXP. DATE <br />Fctimatpr• William Escohgr VALID 1 -% -/ TO Z-1 -to DRIVEWAYS: <br />Applicant Name) STREET j- <br />AREA <br />850 Stillwater Drive TYPErT <br />OUAD <br />Mailing Address) FORMS ky 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: 31162235 <br />Notif. 110283208 <br />Location: 19071 Lower SacramtqtD Rd. <br />Permit drawing, Construction drawing, and permit sketch <br />The undersigned hereby applies for permission to excavate,construct and/or otherwise encroach on County Highway Right-of-Way ontheNorthsideofNOrangeSTapproximately220' feettmile northOfMok-jumv-st by performing the following work(description of work): <br />Replacement ofdeteriorated electric(facility)wood pole <br />Work will commence on or about 12.19.7015 for approximately 30 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 theworkdescribedaboveinaccordancewiththerulesandregulationsofSanJoaquinCountyandsubjecttoinspectionandapproval'. <br />C ll;am C--scl ,7 _ Estimating Engineer 1 n-07.7015SignatureofApplicant-Title Date <br />MSCENTRALSERVICE5CLERICAL`PU&SV.VA$1MWSTER.PSIENCROACHMENTPERMrf APPLCATION.DOC (0913)