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APPLICATION FOR ENCROACHMENT PERMIT <br /> PLEASE PRINT: <br /> Date `C� OFFICE USE ONLY <br /> # % REF <br /> To: San Joacssa.ir_ County JOB CR' <br /> Department of Public Works APN <br /> EXP. DATE 'f 49 <br /> VALID ILY o8 TO a"E DRIVEWAYS: <br /> PG&E ST,EET <br /> AREA :: a c-XTQ J QUAD 11'x_ <br /> 4040 WEST LANE TYPE -15'eu hacE <br /> FORMS w. z5 <br /> STOCKTON, CA 95204 NOTE <br /> (City, State, Zip Code) <br /> �o�l� 2- tG,►21 <br /> (Area Code - Telephone Number) . <br /> Sketch (Detailed pians may be submitted) TRAFFIC CONTROL PLAN <br /> SHALL BE AS PER <br /> CURRENT M.U.T.0 b. <br /> CALIFORNIA SUPPLEPIENJL <br /> SEE ATTACHED SKETCH c <br /> .,m <br /> PM - N :�;, <br /> m :rn <br /> NOTIF: <br /> The undersigned hereby applies for permission to excavate, construct ancyorr- <br /> Riht-of-Wzy on t �� dof <br /> he <br /> otherwise encroach on County Highway g <br /> v pproximately feet/uite <br /> of , by -performing the <br /> _ _foliow'ng _wQxk .(d_sc 'pts on:cif,w rk) <br /> work will commence on 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 Daae <br /> MAS=.PS\FSES0ML RETURN PERMITS TO: <br /> CCD <br /> P6&E <br /> P.O. BOX 930 <br /> STOCKTON,CA 95201 <br />