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APPLICATION FOR ENCROACHMENT PERMIT <br /> PLEASE PRINT <br /> " OFFICE USE ONLY <br /> Date <br /> TO: San Joaquin County JOB REF # <br /> Department of Public Works APP CR # <br /> - EXp. DATE <br /> VALID $4S-01 TO /-07 DRIVEWAYS <br /> (Applicant Name) STREET _`:�& S4-r A * <br /> AREA 5"1 d,-&?VA/QUAD /V <br /> TYPE 44 NO LA <br /> (Mailing Address) FORMS S5 <br /> NOTE <br /> (City, State, Zip Code) <br /> (Area Code - Telephone Number) <br /> Sketch (Detailed plans may be submitted) TRAFFIC CONTROL PLAN <br /> RETURN PEWNIITS 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 /> C <br /> The undersigned hereby applies for permission to .excavate, construct and/or <br /> otherwise-encroach on County-Highway Right-of-Way.-on-the side-of <br /> approximatelyt := ee (mile = '-�' � <br /> s; by :per€orming the <br /> of l._+.a 2 11 TT'- z 4"� ' <br /> Vn <br /> following work (description of work) : 'I i�j t4 (— --- <br /> F M <br /> --FM <br /> Work will commence on or about WA k k7 _r____ 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 ZZ -01 ' L m J't l a t Date <br /> MASTHR.PS\FRES®L (6/00) _ <br />