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APPLICATION FOR ENCROACHMENT PERMIT <br />PLEASE PRINT: <br />Date OFFICE USE ONLY <br />To: San Joaquin County JOB# REF# <br />Department of Public Works APN CR# <br />EXP.DATE S- <br />Ben Kincheloe/PG&E VALID f- I s-/ TO DRIVEWAYS: <br />Applicant Name) STREET uwduie <br />AREA L2 JCA QUAD <br />850 Stillwater Rd TYPE 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 />The undersigned hereby applies for permission to excavate,construct and/or otherwise encroach on County Highway Right-of-Way on <br />the North side of Undine Rd approximately feet/mile <br />of by performing the following work(description of work): <br />Pole Replacement <br />Work will commence on or about- 1vi-Y) t 151)UG-- 12 Ita for approximately 1 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 />2 L /1GK.C/ 2 Consulting Field Engineer 10/10/2015 <br />Signature of Applicant-Title Date <br />M.ICENTRALSERVICESCLERICAUPUB-SV.'NM,MASTER.PSENCROACHMENTPERMfrAPPLICATION.DOC (09113)