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APPLICATION FOR ENCROACHMENT PERMIT <br /> PLEASE PRINT: <br /> Date <br /> �r OFFICE USE ONLY <br /> TO: San Joaquin County JOB #_ ( iJ j 2- ( REF ## <br /> Department of Public Works APN CR' # <br /> EXP. DATE <br /> VALID 31-0"' TOO 1-0e) DRIVEWAYS: <br /> c� (Applicant Name) STREET - <br /> /D ZJ S! Z_A1\. f_ AREA 97-9-AJ QUAD <br /> TYPE <br /> (Mailing Address) FORMS dL/�U -7,7 <br /> /Def1<7D.AJ 1611 NOTE <br /> (City, State, Zip Code) <br /> 9"12. <br /> (Area Code - Telephone Number) <br /> Sketch (Detailed plans may be submitted) <br /> RETURN PERMITS TO: TRAFFIC CONTROL PLAN <br /> PG&E SHALL BE AS PER <br /> JOB PROCESSING DESK, BLD 1 CURRENT M.U.T.C.D. <br /> 4040 West Lane CALIFORNIA SUPPLEMENT <br /> Stockton, CA 05204 <br /> The undersigned hereby applies for permission to .excavate, construct and/or <br /> otherwise- encroach on County Highway Right-of-Way on-the a9OU7'9 <br /> /3 TN �iR�ET side of . <br /> of 7' <br /> approximately SI feet/�.e !. JzfS7- <br /> [)" �S T2EQaS Ta clCTD:t/ <br /> following work (description of work) : by -performing the <br /> EXcs4vsq! '�eBELL <br /> Work will commence on or about <br /> 9D for approximately <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 /> *Skl� ature of Applicant - Title <br /> iia <br /> Date <br /> MASTER.PS\PEES®L (6/00) <br /> i <br />