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APPLICATION FOR ENCROACHMENT PERMIT <br /> PLEASE PRINT: <br /> I Q;� <br /> Date OFFICE USE ONLY <br /> To: San Joaquin County JOB REF # <br /> Department of Public Works APN CR' # <br /> EXP. DATE eV3 <br /> ' DRIVEWAYS <br /> VALID '� <br /> (Applicant Name) STREET <br /> AREA �,7oc= 72n/ QUAD 125 <br /> v "�• TYPE <br /> * <br /> (Mailing Address) FORMS <br /> { a,, NOTE <br /> (City, 'State, :Zip Code) <br /> (Area Code - Telephone Number) <br /> Sketch (Detailed plans may be submitted) TRAFFIC CONTROL PLAN <br /> RETURN PERMITS TO: SHALL BE AS PER <br /> PG&E CURRENT M.U.T.C.D. <br /> JOB PROCESSING DESK, 13LD 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 onthe ` "t +' side of <br /> approximately feet,Ymile ,d�=4 <br /> of y;—_ '°�" ' t4 °€�r=:z=� . by "performing the <br /> following work (description of work) : � � I A`!r t 7 I <br /> y <br /> � i <br /> Work will commence on or aboutfor approximately <br /> E days. E <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 /> Signature of Applicant - Title Date <br /> MASTER.PS\FE&S®L (6/00) <br />