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APPLICATION FOR ENCROACHMENT PERMIT <br /> PLEASE PRINT:* ,, <br /> Date OFFICENLY A��®• 3 <br /> To: San Joaquin_ County <br /> JOB # /052__G REF 1 <br /> Department of Public Works APN CR <br /> EXP. DATE S•/ O� <br /> VALID II•I0-05 TO 504a DRIVEWAYS: <br /> STREET .G�2lLW� A1�. <br /> PG&E AREA. QUAD _ A6 � <br /> 4040 WEST LANE ` OYPE <br /> FORRMS <br /> STOCKTON.- CA 95204 NOTE <br /> (City, State, Zip Code) <br /> LOP z7 <br /> (Ares Code Teleahone Number) <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 <br /> NOTIF: <br /> The undersigned hereby applies for permission to excavate, consa:-uct and/or <br /> otherwise-encroach on County Highway Right-of-way-oa the F. , ff side of <br /> r , approximately, ' feet/fie _ <br /> of ,� ' ? by =per€ornting the <br /> v <br /> sollowing-�,vo.rk___(de,script_ion of_work) --- - ,- <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 Date <br /> MASTM.PS\FSHS®L (5/00) RETURN PERMITS TO: <br /> CCD <br /> PG&E ' <br /> P.O. BOX 930 \ <br /> STOCKTON rA Q;i201 <br />