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APPLICATION FOR ENCROACHMENT PERMIT <br /> PLEASE PRINT: -; <br /> Date r OFFICE USE ONLY <br /> To: San Joaquin. County JOB # REF # <br /> Department of Public Works APN CR # <br /> EXP. DATE <br /> VALID 6/ -0 ICJ--f a Z DRIVEWAYS: <br /> PCME STREET KI IZA N N VE <br /> AREA S otic Cil'-� QUAD /4�`✓' <br /> 4040 WEST LANE TYPE I-,r_L(_ <br /> FORMS <br /> STOCKTON, CA 95204 NOTE T- <br /> (City, State, .Zip Code) <br /> CZo�17�2- t��7 <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 /> NOTIF: <br /> The undersigned hereby applies for permission to .excavate,, construct and/or <br /> otherwise-encroach on County-Highway Right-of-Way-ori.-the <br /> _ approximatel 22 � feet/uLtbe .a�� <br /> of 1 hy',,�,, by be forming the <br /> ----__.._-.__- fallowing--wo-rk—(c etc_-tion of work)_c ? "l <br /> Work will commence on o.: about _ ' ] j ¢j 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 Date <br /> MASTER.ps\FBBs®n (6/00) RETURN PERMITS TO: <br /> CCD <br /> PG&E <br /> P.O. BOX 930 <br /> STOCKTON,CA 95201 <br />