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APPLICATION FOR ENCROACHMENT PERMIT <br /> PLEASE PRINT <br /> Date b - Z`� —Z -7 OFFICE USE ONLY <br /> To: San Joaquin County JOB # _ REF # <br /> Department of Public Works APN CR # <br /> EXP. DATE /O-Ir-O7 <br /> E VALID /0-/-07 TO /0-/_57_07 DRIVEWAYS <br /> (Applicant Name) STREET AO "fji� .Vim. _ <br /> AREA / QUAD <br /> 4U q O �/V C S i LP E TYPED <br /> (Mailing Address) FORMS Lf7 -2 <br /> ct4tNOTE <br /> � G� 2 <br /> (City, State, Zip Code) <br /> Zy!- cT4Z -1 37 <br /> (Area Code - Telephone Number) <br /> Sketch (Detailed plans may be submitted) <br /> TRAFFIC CONTROL PLAN <br /> RETURN PERMITS TO: SHALL BE AS PER <br /> PG&E CURRENT M.U.T.C.b. <br /> JOB PROCESSING DESK, BLD 1 CALIFORNIA SUPPLEMENT <br /> 4040 West Lane <br /> Stockton, CA 95204 <br /> (� �✓p S 8 -� -7,S 1 <br /> The undersigned hereby applies for permission to .excavate, construct and/or <br /> otherwise- encroach on County. Highway Right-of-way on-the 5ovT1,4" side_of <br /> approximately 2r 3Z`j ee/mile 1-:A s <br /> of 4-�w�r �q F . t fr iJ E V---> Lt�fl by performing the <br /> following work (description of work) : �r�s A�-l,iN�-� Z" 5cfLVt'-c5 <br /> 5 Z_12- E Corea act - `x 4 ' c <br /> fGc 2T J — Q OR Sc= p <br /> P1_•� -3 Ff)ZZt'�>-7 <br /> Work will commence on or aboutfor approximately <br /> '1r 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 /> Signature of Applicant Title E-rJ6i ��E" � ? c��`��T Date <br /> MASTER.PS\FnSC®L (6100) <br /> i <br />