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APPLICATION FOR ENCROACHMENT PERMIT <br /> PLEASE PRINT: <br /> Date OFFICE IISS ONLY <br /> To: San Joaquin_ County JOB ## /• 05z '_L) REF # <br /> Department of Public Works APN Cy ## <br /> EXP. DATE <br /> PG&E STREET <br /> 3 /-< TO _8 E:> C DRIVEWAYS <br /> STREET G'ktiLk0iCCF Rb, t <br /> AREA QUAD , <br /> 4040 (NEST LANE TYPE f>c � <br /> FORMS al's <br /> STOCKTON, CA 95204 NOTE <br /> (City, State, .Zip Code) -- - <br /> CZo�l7 a►tl2- l�27 <br /> (Area Code Telephone Number) <br /> Sketch (Detailed plans may be submitted) <br /> TRAFFIC CONTROL PLAN <br /> SHALL BE AS PER <br /> CURRENT M.U.T.C.D. <br /> CALIFORNIA SUPPLEMENT <br /> SEE ATTACHED SKETCH <br /> PM -3,0&149,q,4 C�? <br /> NOTIF: to W O 214 <br /> The undersigned hereby applies for permission to .excavate, co struct and/or <br /> oth.erw'se- encroach on County Highway Right-of-Way on-the side-of <br /> approximately —� feet/ 3e 51 LAL <br /> of '101� - - by performing the <br /> followingwox_k,-( _script,ion of,work)_: p <br /> L111;rZA" <br /> OA <br /> Work willcommenceon or about 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 /> S ature of Applicant - Title D to <br /> MASTM-PS\FnS®L (6/00) RETURN PERMITS TO: <br /> CCD <br /> PG&E <br /> P.O. BOX 930 \ <br /> STOCKTON,CA 95201 <br />