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APPLICATION FOR ENCROACHMENT PERMIT <br /> PLEASE PRINT: ' <br /> Date # OFFICE USE ONLY <br /> To: San Joaquin County JOB# REF# <br /> Department of Public Works APN CR# <br /> EXP.DATE /l <br /> Pacific Gas and Electric Co. VALID z&6111 0 DRIVEWAYS: <br /> STREET <br /> P.O. BOX 930 AREA Lo QUAD _w� <br /> Stockton, CA 95201 TYPE mit _ <br /> FORMS <br /> NOTES TT <br /> (Area Code.Telephone Number) <br /> Sketch(Detailed plans may be submitted) <br /> Traffic Control Plan i <br /> SEE ATTACHED SKETCH Shall be as.per <br /> PM current M.U.T.C.D. i <br /> � <br /> a� j California supplement. <br /> NOTIF: � ���" � G���U I <br /> The un ersigned hereby applies for permission to excavate,c nstruct and/or otherwise encroach on County Highway Right-of Way on <br /> the {' side of tl <br /> of approximately 1 A 167— feet/mi le-ham <br /> _ �' p1 _ by performing the following work(descri tion of wa): <br /> V t <br /> Work will commence on or about for approximately I 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 �I <br /> Date <br /> e-SV'WMVSTERPS"CROAMEMPMUAPPUCAT10KDOC (M)M <br /> Return permits to: <br /> CCD <br /> P.O. Box 930 <br /> Stockton, CA 95201-0930 <br />