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APPLICATION FOR ENCROACHMENT PERMIT <br /> PLEASE PRINT: <br /> Date ✓ OFFICE USE ONLY <br /> TO: San Joaquin Count,yr JOB # 7 �rZ'CP REF # <br /> Department of Public Works APN CR # <br /> EXP. DATE S'�• <br /> VALID O-W.OS TO DRIVEWAYS: <br /> PG&E STREET �v <br /> AREA c &tJ QUAD 15r=> <br /> 4040 WEST LANE TYPE -sSt_t_ HoL s <br /> FORMSr�s' Z! <br /> STOCKTON, CA 95204 NOS <br /> (City, State, Zip Code) <br /> ( 017 A2 <br /> (Area Code Telephone Number) <br /> - <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 uoei I <br /> NOTIF: (or)2 too-ft <br /> The undersigned hereby applies for permission to excavate, construct and/or <br /> otherw'se-encroach on count Hi hwa R' ht-of-Wa on the s-de f <br /> approximatelyfeet/ <br /> of • �� by "performing the <br /> ,b <br /> _(description of,work) : <br /> Work will commence on or about kolZe for approximately <br /> days. <br /> I, the undersigned certify that I am the owner of. the re spective, 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 andsubjectto <br /> inspection and approval. <br /> 01 <br /> S ature of Applicant - Title D to <br /> MASTM.Ps\Fass®n (6100) RETURN PERMITS TO: <br /> CCU <br /> P&(&E <br /> P.O. BOX 930 \ <br /> - - C_rnrV'r/'1A1 rn n;;I)nl <br />