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APPLICATION FOR ENCROACHMENT PERMIT <br /> PLEASE PRINT: <br /> Date OFFICE USE ONLY <br /> To: San Joaquin County JOB# 1 �,2- REF# <br /> Department of Public Works APN CR# <br /> EXP.DATE <br /> Pacific Gas and Electric Co. VALID DRIVEWAYS: <br /> STREET � • <br /> P.O. BOX 930 AREA QUAD <br /> Stockton, CA 952011 TYPE <br /> FORMS 55 4Z-.2 <br /> NOTES <br /> (2,0q ) 942- 162'1 <br /> (Area Code-Telephone!Number) <br /> Sketch(Detailed plans may be submitted) <br /> Traffic Control Plan <br /> SEE ATTACHED ' KETCH Shall be as per <br /> PM �x�.. � `.��� current M.U.T.C.D. <br /> California supplement. <br /> NOTI F: I L;4.6; -1 -7 <br /> The undersigned hereby applies for permission to excavate,construct and/or otherwise encroach on County Highway Right-of-Way on <br /> the 'M <br /> side of i�aye".�_ approximately feet/m k i<s� <br /> of fir') by performing the following work(description of wor ): <br /> f Y � <br /> Work will commence on or about_ for approximately ?'=l _ 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 /> Signature of Applicant-Title Date <br /> L-SV.WKVAASTER.PWNCRDACAMENT PSWIT APPUCATIUK03C (CIM) <br /> Return permits to: <br /> CCD <br /> P.O. Box 930 <br />