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APPLICATION FOR ENCROACMdENT PERMIT <br /> PLEASE PRINT. ,; <br /> Date r OFFICE USE ONLY <br /> To. San Joaquin_ County JOB # REF # <br /> Department of Putlic Works APN _ CY # <br /> EXP. DATE S •!S.••O <br /> /±p VALID %l•10•a$ TO S•!S•aq DRIVEWAYS: <br /> PG&E STREET Dy19�/ <br /> AREA 564e-.,416,2 QUAD <br /> 4040 WEST LANE TYPE <br /> FORMS <br /> STOCKTON, CA 95204 NOTE <br /> (City, State, Zip Code) <br /> Zo�i7 &-Z•- 1&2.-7 <br /> (Area Code - Telephone Number) <br /> Sketch (Detailed plan's may be submitted) <br /> 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 /> MOTIF <br /> p hundersigned onstruct and/or <br /> ohexwiseeroachhereby onapplies <br /> on to <br /> Countgo <br /> Highway Right -W athee� ssode of - <br /> approximately feet/mile <br /> of by per€or3ming the <br /> work___(deScrz.ptionof:w rkL_. mow' _ at' <br /> --s--- <br /> ».- --r' <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 /> tSature of Applicant Title Date <br /> MUTSR.PS\HSPS®L (6100) RETURN PERMITS TO: <br /> CCD <br /> P&&E <br /> P.O. BOX 930 �. <br /> STOCkTON CA 9F"i901 <br />