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APPLICATION FOR ENCROACHMENT PERMIT <br /> PLEASE PRINT:' <br /> Date �G' OI F'= USE ONLY <br /> To: San Joaquin_ County JOB # S05;_('r REP # <br /> Department of Public Works APN _ CR # <br /> EXp. DAT <br /> VALID �` DRIVEWAYS: <br /> PGBtE STR T <br /> AREA Qom - <br /> 4040 WEST LANE TYPE <br /> FORMS �s <br /> STOCKTON, CA 95204 NOTE <br /> (City, State, Ziv Code) <br /> CZr�17�Id2 1&2.'7 <br /> (Area Code - Telephone Number) . <br /> sketch (Detailed plans may be submitted) <br /> TRAFFIC CONTROL PLAN <br /> SHALL BE AS PER z, ­-, <br /> N <br /> CURRENT M_U.T.C.D. ` o ffi <br /> CALIFORNIA 5UPPLEMENT <br /> c rn <br /> SEE ATTACHED SKETCH <br /> CD c rn <br /> r�. <br /> PM <br /> NOTIF: ori 6,,be � <br /> 4 <br /> The undersigned hereby applies for permission to excavate, c nsa ct and/or <br /> otherwise-encroach on County Highway Right-of-Way on the A66 side of <br /> approximatel '5 feet/tie tn14"1 <br /> of CA J: t; by "performing the <br /> olloswin -pork _(_description of work)_ _ ' <br /> Work will commence on or about q ISZ for approximately <br /> b�>a 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 /> � �maOMIS <br /> S ature of Applicant - Title Daae <br /> rmsrszt.PS\FnS®L (6/00) RETURN PERMITS TO: <br /> CCD <br /> PG&E <br /> P.O. BOX 930 <br /> STOCKTON CA 95201 <br />