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APPLICATION FOR ENCROACHMENT PERMIT <br /> PLEASE PRINT: <br /> Date �: . -` Orncz USE ONLY <br /> To: Sar_ Joaquin County JOB # 'Ye �— o REQ' <br /> Department of Public Works APN CR # <br /> EXP. DATE <br /> VALID 6-4'4�e TO DRIVEWAYS: <br /> PG&E STREET <br /> AREA ` QUAD <br /> 4040 WEST LANE TYPE 1 - 4EL(C4 <br /> FORMS <br /> STOCKTON, CA 95204 NOTE <br /> (City, State, Zip Code) <br /> CO2.7 <br /> (Area Code - Telephone Number) <br /> Sketch (Detailed plans may be submitted) TQ?AFcIC CONTROL PLAN <br /> SHALL BE AS PFR <br /> CURRcNT M,I j T C_b <br /> CALIFOPZ IA SuPPLEMt� l T <br /> SEE ATTACHED SKETCH <br /> PM � - <br /> NOTIF <br /> The undersigned hereby applies for permission to excavate, construct and/or <br /> otherwise encroach on County-:Highway Right-of-Wa on the Aide of <br /> approximately - <br /> af "l by "perrormir_g the <br /> _ rollow *zg_wo' k _.(d scrzpton of_work)_ <br /> Work will commence on or about for approximately <br /> i�4; 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 /> rte, <br /> Sature of Applicant - Title Date <br /> MASTs.Y.PS% MS®L (6100) RETURN PERMITS TO: <br /> CCD <br /> PG&E <br /> P.O. BOX 930 <br /> STOCKTON,CA 95201 <br />