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APPLICATION FOR ENCROACHMENT PERMIT <br /> PLEASE PRINT: <br /> --7 <br /> Date <br /> Date -fv OFFICE USE ONLY <br /> To: San Joaquin County JOB # 73d5Z'G REF <br /> Department of Public Works APN _ CR 0-- <br /> EXP. DATE '07 <br /> VALID TO /0+/-07 DRIVEWAYS: <br /> (Applicant Name) STREETL 1�• <br /> / AREA 08/ QUAD <br /> TYPE 0249, P.E . 7zlem ly* <br /> (Mailing Address) FORMS SLI/a/!f/, <br /> �� ,�✓, �, NOTE <br /> }}(C ty/, State, Zip Code) <br /> �77 <br /> `� / �' - � v//3564 <br /> (Area Code - Telephone Number) <br /> Sketch (Detailed plans may be submitted) TRAFFIC CONTROL PLAN <br /> j Z /7Z 7 SHALL BE AS PER <br /> 3. �� 1 CURRENT M.U.T.C.D. <br /> CALIFORNIA SUPPLEMENT <br /> RETURN PERMIYS M. S�e " r nl 22 <br /> PG&E <br /> .JOB PROCES811VC3 WSK u SW 1 <br /> gT�ACKTON, CA 9M4 <br /> The undersigned hereby applies for permission to .excavate, construct and/or <br /> otherwise-enf roach on County Highway Right-of-Way oa-the ��S7'-V-I'll side:of/ J <br /> i E? approximately /mile `, f'/T/7 <br /> of I/ C. �� '�� .�+�y� /�- Z;)i by�" per€orminrg the <br /> following work (description of wort) : ) .� fve• n/ Lac 4- X " <br /> T4s e 'UX. ' Al c %? ,l t'G / /V <br /> S� ✓lc �C- i P'i rci 1//lJ f�7 S /t? ('i S 1 v. �? 'i�'- �'e ✓Z.: - <br /> � - <br /> J <br /> Work wi/l� commence on or about / � O for approximately <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 /> Signature of Applicant - Title g :010 61 NN LO Date <br /> MASTER.PS\PEESCEML (6/00) <br /> e <br /> C <br />