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APPLICATION FOR ENCROACHMENT PERMIT <br /> PLEASE PRINT <br /> Date OFFICE USE ONLY <br /> To: San Joaquin County <br /> JOB # REF # <br /> Department of Public Works APN _ CR # <br /> EXP. DATE 15 <br /> �r E Co . VALID )To <br /> .� TO �� DRIVEWAYS: <br /> (Applicant Name) STREET <br /> AREA STJZAJ QUAD <br /> yv es k N TYPE H014- <br /> (Mailing <br /> OLE(Mailing Address) FORMS <br /> NOTE <br /> (City, State, Zip Code) <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 I CALIFORNIA SUPPLEMENT <br /> 4040 West Lane <br /> Stockton, CA 95204 <br /> The undersigned hereby applies for permission to .excavate, construct and/or <br /> otherwise-encroach on County- Highway,hwaY_ Right-of-Way.-on.the SOUT111k side.of <br /> approximately ee /mile _W6511- <br /> of <br /> ES1of /itlG 5'TD Ca4x'c�nl.:. . by performing the <br /> following work (description of work) : ti� I ' ( Y-& y 'VL_ Ei�S S�,e�/rcC <br /> 'Tb 2 4 4 E <br /> c�\3 <br /> Work will commence on or about L-Aye U6&JS'- 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 /> Si ature of Applicant - Title �1Z :01 sl v1 i Date <br /> MASTER.PS\"9SCOML (6/00) <br /> II <br />