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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• S S- TO %�✓'_=<� DRIVENAYS <br /> PG&E STREET 4e­4,-,'e2XZI: <br /> AREA /ct,'yT• QUAD �... <br /> 4040 WEST LANE TYPE `S <br /> FORMS <br /> STOCKTON, CA 95204 NOTE <br /> (City, State, .Zip Code) <br /> r�172- 1027 <br /> (Area Code Telephone Number),_ <br /> Sketch (Detailed plans may be submitted) TRAFFIC CONTROL PLAN <br /> SHALL BE AS PER <br /> CURRENT M.U.T.C.D. <br /> CALIFORNIA SUPPLEMENT <br /> SEE ATTACHED SKETCH <br /> PMS <br /> NOTIF: toZb oga'q <br /> The undersigned he applies for permission to .excavate, _ onstruct and/or <br /> otherwise--encroach on C untHi hwa Ri ht-of-Wayon the ide..of <br /> y � 5� Y. g <br /> approximately _ feet/ <br /> of d , by"performing the <br /> owi Ya k crption of-work)._ ot <br /> Work will commence on or about 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 Joagwin County and subject to <br /> inspection and approval. <br /> - <br /> S ature of Applicant Title ;01 ' J'7 nate <br /> MASTM.PS\MMS®L (e/oo) RETURN PERMITS TO: <br /> CCD <br /> P&&E <br /> P.O. BOX 930 \ <br /> STOCKTON,CA 95201 <br />