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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 <br /> CR# <br /> EXP.DATE <br /> Pacific Gas and Electric Co. VALID o s'f DRIVEWAYS: <br /> P.O. BOX 930 ' STREET ,,,w <br /> AREA <br /> QUAD <br /> Stockton, CA 95201 TYPE � � • �,� <br /> FORMS <br /> NOTES <br /> (2101 ) ,942- <br /> (Area Code-Telephone Number) <br /> Sketch(Detailed plans may be submitted) <br /> SEE ATTACHED SKETCH Traffic Control Plan <br /> Shall be as per <br /> PM �F o current M.U.T.C.D. j <br /> NOTI F: , r, g j California supplement. <br /> The u dersig ed hereby applies for permission to excavate, onstruct and/or otherwise encroach on County Highway Right-of-Way on <br /> the side of ' <br /> of approximately S r feeYwk <br /> by performinq the following work(description of work): <br /> Work will commence on or about for approximately .-, <br /> -----.._....,;_�-� .� nays. <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 — $ <br /> Date <br /> �.SV'WOAASTEUSENMA"ENTPMMrTAMucAnOXUX MI" - <br /> Return permits to: <br /> CCD <br /> P.O. Box 930 <br /> -qtnnktnn ('A 95701-0930 <br />