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APPLICATION FOR ENCROACHMENT PERMIT <br /> PLEASE PRINT: <br /> Date R —ll-Z) 7 OFFICE USE ONLY <br /> To: San Joaquin Count,y JOB # /3X>sz-� REF # <br /> Department of Public Works APN _ CR' # <br /> _ EXP. DATE - - <br /> �f T;AS �L'L�Cl. �y VALID TO 5 DRIVEWAYS: <br /> (Applicant Name) STREET <br /> VO 1-16 Z JAS i l-c'A-/L AREA >v� QUAD (L4 <br /> TYPE h _ <br /> (Mailing Address) FORMSTZ)If 1-117_z)XJ4 z7W <br /> NOTE <br /> (City, State, Zip Code) <br /> 20r 9y2 - lI/5',0 <br /> `-tArea 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 I 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 ,D 1-1-r- / side of <br /> L_Jl4L LE 1Z /�U, approximately SS feet/wA&e LJEST <br /> of aS'TUCt(TD��- by-performing the <br /> following work (description of work) : <br /> /� L-X��svrr-�!= �L; T/l <br /> GAS 179111 l! /7lUL) %/�L-�/�// TU 2'RyP1--ZT"y <br /> vAS' <br /> Work will commence on or about 1-21 -'023 for approximately <br /> 90 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 /> v vs �, - ��. JAS <br /> FTgnature-of Applicant: - Title Date <br /> MASTSR.PS\PBBSC®L (6/00) <br />