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APPLICATION FOR ENCROACHMENT PERMIT <br /> PLEASE PRINT: <br /> Date OFFICE USE ONLY <br /> To: San Joaquin County <br /> JOB # a d`� Z REF # <br /> Department of Public Works APN CR # <br /> EXP. DATE <br /> VALID. TO _(—ZO — DRIVEWAYS <br /> PG&E STREETS <br /> AREA St o Q <br /> 4040 WEST LANE TYPE <br /> FORMS 513 Ili 1 <br /> STOCKTON, CA 95204 NOTE <br /> (City, State, Zip Code) <br /> k 2b9��2- Ot�2? <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 /> PM <br /> NOTIF: <br /> The undersigned hereby applies for permission to excavate, construct and/or <br /> oherwise- encroach on County Highway Right-of-W2 an the ��"iY ~� side of <br /> d approximately `' feet/mil-Ar <br /> of ° "*V . "perfoxm:'rng the <br /> _ o�loSving_work.__(description of work? <br /> Work will commence or_ or about a 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 /> o. <br /> Sazure of Applicant - Title Q :01 WV L 'NF 1rlm <br /> MAST$R.Bs�?88s®n cs/aol RETURN PERMITS TO: <br /> CCD 03A13 ",3e <br /> PG&E <br /> P.O. BOX 930 <br /> STOCKTON,CA 95201 <br />