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- <br />\ <br />APPLICATION FOR ENCROACHMENT PERMIT <br />PLEASE PRINT: <br />Date <br />To: <br />01/25/2016 <br />San Joaquin County <br />Departmentof Public Works <br />PG&E <br />(Applicant Name) <br />4040WESTLN <br />(Mailing Address) <br />STOCKTON,CA 95204 <br />(City,State,Zip Code) <br />209-942-1421 <br />JOB# <br />APN <br />EXP,DATE <br />VALID <br />STREET <br />AREA <br />TYPE <br />FORMS <br />NOTES <br />DRIVEWAYS: <br />• <br />(Area Code.Telephone Number) <br />Sketch (Detailed plans may be submitted) <br />SEE ATIACHED SKETCH <br />The undersiqned hereby applies for permission to excavate,construct and/or otherwise encroaqh on County Highway Right-of-Way ontheSOUTHsideofDouglasRdapproximately593feeUmileEAST <br />of Harrisburg PL Stockton,by performingthe following work (description of work): <br />EXCAVATE (1)4'x4'BELLHOLE TO REPLACE EXISTING GAS SERVICE TO 1923 Douglas Rd PM 31210170 <br />Work will commence on or about _4/_1/_2_0_16 for approximately_~6~0 days, <br />01/25/2016 <br />Date <br />,I/"'v." <br />a ure of Applicant.Title <br />I,the undersigned,certify t m the 0 er of the respective property,or am qualified to represent the owner and agree to do the <br />work described abov 'accord'Iththe rules and regulations of San Joaquin County and subject to inspection and approval. <br />E:\PUB.sv.WKlMASTER.PSlENCROACHMHIT PERMlT APPLICATIONDOC (01/QS)