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APPLICATION FOR ENCROACHMENT PERMIT <br /> PLEASE PRINT: <br /> Date -� OFFICE USE ONLY <br /> To: San Joaquin County JOB # �� �' REF # <br /> Department of Public Works APN CR # <br /> EXP. DATE <br /> F e- C VALID - c TO DRIVEWAYS: <br /> (Applicant Name) STREET � J9 LU, <br /> AREA Nc-e, QUAD N ' <br /> TYPE <br /> (Mailing Address) FORMS �2�r-t,- �"� <br /> NOTE <br /> (City, State, zip Code) <br /> Llc � s � <br /> (Area Code - Telephone Number) <br /> sketch (Detailed plans may be submitted) TRAFFIC CONTROL PLAN <br /> RETURN PERMITS TO: SHALL BE AS PEP <br /> PG&E CURRENT M.U.T.C.D. <br /> JOB PROCESSING DESK, BLD 1 CALIFOPNIA SUPPLEMENT <br /> 4040 West Lane <br /> Stockton, CA 95204 <br /> C_> 'C "� ' <br /> The undersigned hereby applies for permission to excavate, construct and/or <br /> otherwise encroach on County, Right-of HighwayRi on-the Vj�5s- side_of <br /> . <br /> 's— p t c � approximately :"Gx: feet./magT <br /> of tby.—performing the <br /> following work (description of;work) : V-Z- r k­k�'Pk_ CSS <br /> 'Z � 'VA <br /> �j ye <br /> M i CJTIE,"M,5i� <br /> Work will commence on oxabout ►`-lA 1 J 20 for approximately <br /> 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 /> Si ature of Applicant - Title Daae <br /> MASTER.PS\EBBS®L (6/00) <br />