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APPLICATION FOR ENCROACHMENT PERMIT <br /> PLEASE PRINT: <br /> Date 1 OFFICE USE ONLY <br /> To: Sar_ Joaquin_ County JOB #¢ t J'> REF <br /> Department of Public Works APN _ CRr <br /> EXP DATE <br /> VALID 1- TOi_ `�• DRIVEWAYS:. <br /> STREET LV <br /> PCME AREA i QED <br /> WEST LANE FORMS 1--- <br /> 4040 <br /> STOCKTON, CA 95204 NOTE <br /> (City, State, Zip Code) <br /> (2bq:)!aj2- I&V <br /> (Area Code - Telephone Number) <br /> Sketch (Detailed plans may be submitted) <br /> TRAFFIC CONTROL PLAN <br /> SHALL BE AS PER <br /> CURRENT tkl.0 T C D. <br /> CALIFORNIA SUPPLEIMcNT <br /> SEE ATTACHED SKETCH <br /> PM <br /> NOTIF: b 17 t <br /> The undersigned hereby applies for permission to excavate, const uco and./or <br /> otherwise-encroach-,on County- HJgnway Right-of-Way on the side of <br /> approximately feet/ra T <br /> of 41"�f� , by "�er€orming the <br /> _following_wo.rk__ desc, ipp on of,work_)_ <br /> � <br /> 't <br /> Work will commence on or about 7 loo 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 Date <br /> K;L=.PS\_7R3SaML (6/00) RETURN PERMITS TO: <br /> CCD <br /> PG&E <br /> P.O. BOX 930 <br /> STOCKTON,CA 95201 <br />