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APPLICATION FOR ENCROACHMENT PERMIT <br /> PLEASE PRINT: <br /> Date G2 OFFICE USE ONLY <br /> TO: San Joaquin County JOB # 75052-6 REF # <br /> Department of Public Works APN CR # <br /> EXP. DATE r 2/3.16 7 <br /> VALID to TO _ IZ1261,57 DRIVEWAYS: <br /> (Applicant Name) STREET <br /> �-j2 e AREA QUAD <br /> eij I <br /> TYPE ���?alc � �61Y'e <br /> (Mailing Address) S <br /> FORMS '5/4✓w R-99 <br /> q NOTE <br /> (City, State, Zip Code) <br /> (Area Code - Telephone Number) <br /> Sketch (Detailed plans may be submitted) <br /> TRAFFIC CONTROL PLAN <br /> `_j e- T-C,I� SHALL BE AS PER <br /> CURRENT M.U.T.C.b. <br /> CALIFORNIA SUPPLEMENT <br /> RETURN PERMITS TO: <br /> PG&E <br /> _� �� JOB PROCESSING DESK, BLD 1 <br /> PIA 6 4040 West Lane <br /> Stockton, CA 95204 <br /> The undersigned hereby applies for permission to .excavate, construct and/or <br /> otherwise-encroac on County Highway Right-of-Way-on-the T sid .of <br /> approximately feet mile <br /> of bv - erforming the <br /> following work (description of work) : <br /> Work will commence on or about l0 O for approximately <br /> �D <br /> days. <br /> I, the undersigned certify that I am the owner of the re spective, 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 /> c2 <br /> Signature of Applicant Title Date <br /> MAST&R.PS\FSBS®L (6/00) _ J.1 'o{ �f LZ <br /> J�y1ti �.`+37 . <br /> 1 F <br />