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APPLICATION FOR ENCROACHM NT PERMIT <br /> PLEASE PRINT: <br /> f } OFFICE USE ONLY <br /> 1 <br /> Date <br /> JOB I �oeSZ �, REF <br /> To: San Joaguir_ County ApN CR a# -- <br /> Department of Public Works <br /> EXP. DATE <br /> VALID TO 1=_L- c(T, DRIVEWAYS: <br /> PSTREET +�� ve <br /> GE QUAD <br /> 4040 WEST LANE TYPE <br /> Foms <br /> STOCKTON, CA 95204 NOTE <br /> (city, State, Zip Code) <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 /> NOTIF: s <br /> The undersigned hereby applies for permission to excavate, construct and/or <br /> ' �t `� <br /> otherwise- encroach on County=8ighway ?�rght-of-Wz Y on-the the side of <br /> an roximatelye`l �''?� feet/me- <br /> of ns , by -- rforming the <br /> foliowing--wdk_(descrsPt, o _.�of_work} :-- ¢ --------- -_ <br /> - -- - - -— <br /> Work will commence on or about ,.� y •'`r for approximately <br /> �_. days r <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 00 '0I iib Date <br /> MAST3R.PS\-33S®L (6/00) RETURN PERMITS TO: j# J3 'I.'(1c. • _ <br /> CCD <br /> (13AI3038 <br /> PG&E <br /> P.O. BOX 930 <br /> STOCKTON,CA 95201 <br />