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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 /> VALID DRIVEWAYS: <br /> (Applicant Name) STREET 1. * <br /> AREA QUAD <br /> VJ"c`J.I, LAN TYPE J �4 o l <br /> (Mailing Address) FORMS <br /> G NOTE <br /> (City, State, Zip Code) <br /> �v tet ) (1.+L G�3 <br /> (Area Code - Telephone Number) <br /> Sketch (Detailed plans may be submitted) <br /> TRAFFIC CONTROL PLAN <br /> RETURN PERM:[TS TO: SHALL BE AS PER <br /> PG&E CURRENT M.U.T.C.D. <br /> JOB PROCESSING DESK, BLD 1 CALIFORNIA SUPPLEMENT <br /> 4040 West Lane <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 E1J '" side of <br /> 1-A 1 � approximately eet/mile c5- T1 <br /> of to j-,>`i�- play -performing the <br /> following work (description of work) : i �.15^�, L_#._ <br /> .L-a r r> _ <br /> Work will commence on or about W41 0 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 /> �3. ature of Applicant - Title 1 z :p( H y . Date <br /> MASTER.PS\FRES®L (6/00) <br />