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APPLICATION FOR ENCROACHMENT PERMIT <br /> PLEASE PRINT., <br /> Date OFFICE USE ONLY <br /> To : San Joaquin County JOB # /, i�`7, REF # <br /> Department of Public Works APN CR # <br /> ( EXP. DATE _ <br /> VALID i2 3\-oma TO _ -(-� DRIVEGPAYS: <br /> (Applicant Name) STREET K�-,_ejc L A*- <br /> _ AREA _f' K A/ QUADn e5 <br /> y0yo 1.�.)z.5 r L_191(lL TYPE Fi_C 14 e7 i"E_ . f� 1 i1� <br /> (Mailing Address) FORMS ALuli; <br /> d5 rL0L?/<rDA1 NOTE OV `�5�2D <br /> (City, State, Zip Code) <br /> 14)"qz <br /> (Ara Code - Telephone Number) <br /> Sketch (Detailed plans may be submitted) <br /> TRAFFIC CONTROL PLAN <br /> RETURN PERMITSTO: <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 95204 <br /> The undersigned hereby applies for permission to .excavate, construct and/or <br /> otherwise- encroach on County Highway Right-of-Way on-the S,0L.1T1--1 side of <br /> E. approximately 395 feet/rr e L4..)G37 <br /> of C`9RL>zk14L �l�E. _ 97DCK7'0A1by -performing the <br /> following work (description of work) EXG�[/l9TE /3L LL /��LE DuE�2 <br /> TiS�E Z,4_S /?71VIAI 4.n111 O�� TING a4Z'e2EL�Z" Ty _Z/i/.�Ti9 i_ /V Aka&_) <br /> work will commence on or about 12 ' 31-0; for approximately <br /> 4D 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 /> pp , <br /> 49. Z.5 LSE141112720 <br /> 49 <br /> nature of Applicant Title Date <br /> MASTER.PS\MS®L (6/00) - <br /> I <br />