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9 <br /> t <br /> APPLICATION FOR ENCROACHMENT PERMIT <br /> PLEASE PRINT: <br /> Datew vC17 OFFICE USE ONLY <br /> To: San Joaquin County JOB 73652-6, REF # <br /> Department of Public Works PPN CR # <br /> EXP- DAT <br /> VALID TO / DRIVEWAYS. <br /> (Applicant Name) <br /> STREET luOl17 <br /> AREA_'57 Tont QUAD .(/S <br /> 57"- Z/114 TYPE <br /> — <br /> (Mailing Address) FORMS <br /> NOTE <br /> 4 <br /> (City, State, Zip Code) <br /> " (Area Code - Telephone Number) <br /> Sketch (Detailed plans' may be submitted) p C � <br /> N 00 <br /> TRAFFIC CONTROL PL N en ? <br /> SHALL BE AS PER �n <br /> CURRENT M.U.T.C.D. <br /> PM; 3051!0!0!0 CALIFORNIA SUPPLEMENT <br /> The undersigned hereby applies for permission to excavate, construct and/or <br /> otherwise en cro ch on C:_ounty Highway Right-of-Way on the 0 side of <br /> 0Z(J S7: approximately Z OZ.' feet mile <br /> by performing the <br /> of <br /> following work (des ription of work) : DI h V1 d <br /> .occ ss We, roO <br /> i U c✓ <br /> Work will commence on or about for approximately <br /> Z. o days <br /> I, the undersigned cert=ify that I am the owner of the respective property, or am <br /> qualified to represent the owner and agree to do the work described above in <br /> accordance with the ru-Ces, regulations of San Joaquin County and subject to <br /> inspection and approval. <br /> Signat.ua of Appfica.nt - Title RETURN PERMITS TO: Data <br /> PG&E <br /> HASTE2.P5••,FEESGT{DI. (6/40) PROCESM DEW_BW <br /> 1 <br /> C <br />