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APPLICATION FOR ENCROACHMENT PERMIT <br /> PLEASE PRINT: <br /> Date 4/Z ho OFFICE USE ONLY <br /> To: San Joaquin County JOB# REF# <br /> Department of Public Works APN CR# <br /> EXP.DATE ID-i •ZO)D <br /> Pacific Gas and Electric Co. VALIDTO iD-!5'•Aodv DRIVEWAYS: <br /> STREET C�EytTyZt�flE Y,�E <br /> P.O. BOX 930 AREAQUAD <br /> Stockton, CA 95201 TYPE ,vim .t 7;r6AZH <br /> FORMSJ , <br /> NOTES <br /> (2,Oq ) `942- 1627 <br /> (Area Code-Telephone Number) <br /> Sketch(Detailed plans may be submitted) <br /> Traffic Control Plan <br /> See attached sketch. Shall be as per <br /> PM eW765eAl current M.U.T.C.D. <br /> Notif. I b42.&411 California supplement. <br /> The ndersi ned hereby applies for per ission to excavate,construct and/or otherwise encroach on County Highway Right-of-Way on <br /> the side of (,(' INj[e, _approximately feet4ok 4� <br /> of4 4W by performing theollowing work(description of work): <br /> Work will commence on or about ATF—Zh2i for approximately days. <br /> I,the undersigned,certify that I am the owner of the respective property,or am qualified to represent the owner and agree to do the <br /> work described above in accordance with the rules and regulations of San Joaquin County and subject to inspection and approval. <br /> ,-3bd� - duo 4 12 <br /> Signature of Applicant-Title ate <br /> Lr,VWKUASTEFLPS"CRC)ACHMENTPEPAffAPPLICAT]OKOOC (071011) <br /> Return permits to: <br /> CCD <br /> P.O. Box 930 <br /> Stockton, CA 95201-0930 <br />