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APPLICATION FOR ENCROACHMENT PERMIT <br /> PLEASE PRINT <br /> Date 4-d OFFICE USE ONLY <br /> To: San Joaquin County JOB # (o REF # <br /> Department of Public Works APN CR' # <br /> EXP. DATE <br /> VALID ?-x-','-b 7 TO A-/57-67 DRIVEWAYS <br /> (Applicant Name) STREET " * <br /> AREA ':! Orlo 0' QUAD <br /> w��iii E TYPE 9G <br /> (Mailing Address) �1 FORMS <br /> NOTE <br /> (City, State, Zip Code) <br /> - X47--- 1S3 -1 <br /> (Area Code - Telephone Number) <br /> Sketch (Detailed plans may be submitted) TRAFFIC CONTROL PLAN <br /> RETURN PERMITS TO: SHALL BE AS PER <br /> PG&E CURRENT M.U.T.C.D. <br /> JOB PROCESSING DESK, BLD 1 CALIFORNIA SUPPLEMENT <br /> 4040 West Lane <br /> Stockton, CA 952.04 <br /> The undersigned hereby applies for permission to excavate, construct and/or <br /> otherwise;encroach on County. Highway Right-of-Way-on-the A.'> side.of <br /> approximately L-7o (feed/mile �—OL'T_H <br /> of ��P�1J� R►i,tj �1�: S nL-�1�yr� by"performing the <br /> following work (descript.ion of work) : 5 P � �-- <br /> C �j C ✓ z I �. s. S a <br /> �z <br /> Work will commence on or, about -Z0 fD for approximately <br /> 7! <br /> days. <br /> I, the undersigned certify 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 rules, regulations of San Joaquin County and subject to <br /> inspection and approval. <br /> ';nature of Applicant - Title :01 is ! hjy t � Date <br /> MASTER.PS\FEES®L (6/00) <br /> CJ, <br /> e , <br />