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APPLICATION FOR ENCROACHMENT PERMIT <br />PLEASE PRINT: <br />Date 07-24-2015 OFFICE USE ONLY <br />To: San Joaquin County JOB# t 1 ?-18 REF# <br />Department of Public Works APN CR# <br />Job Owner: Kimberly Van Fleet EXP. DATE <br />Estimator- William Escobar VALID j i i TO _ ' ;- DRIVEWAYS: <br />Applicant Name) STREET <br />AREA QUAD S <br />850 Stillwater Drive TYPE <br />Mailing Address) FORMS Ci; iAl" <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: 31139867 <br />Notif: 110006852 <br />Location: 4469 S. Escalon Bellota Rd, Farmington <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 ontheNorthsideofCA-4 Highway approximately 1551 feet/mile west <br />of S. Escalon Bellota Rd. by performing the following work(description of work): <br />Replacement of deteriorated electric(facility)wood pole. <br />Work will commence on or about 10-10-2015 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 />Cti illru r 6-jc-hb - Estimating Engineer 07-24-2015 <br />Signature of Applicant-Title Date <br />MXENTRALSERVICES',CLERICAL',PI_9 W MASTER.PS'.ENCROACHAIENTPERPAIT APPLICATION DOC (09,13)