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APPLICATION FOR ENCROACHMENT PERMIT <br /> PLEASE PRINT: j <br /> Date ` l OFFICE USE ONLY <br /> To: San Joaquin County JOB# REF# <br /> Department of Public Works APN CR# <br /> EXP.DATE Z /s// <br /> VALID /3 / T S DRIVEWAYS: <br /> Pacific Gas & Electric STREET A�� �• k <br /> P.O. BOX 930 AREA ?/�-A QUAD -11r– <br /> TYPE Aglive <br /> STOCKTON, CA 95201 FORMS *40j2- <br /> 17 <br /> 209-942-1627 NOTES <br /> Sketch(Detailed plans may be submitted) <br /> Traffic Control Plan <br /> shall be as per <br /> See attached sketch. current M.U.T.C.D. <br /> California supplement <br /> PM 3o84,Cv l <br /> Notif. I <br /> The undersigned hereby applies far permission to excavate,construct and/or otherwise encroach on County Highway Right-of-Way on <br /> the side of ' A —approximately `71 feeVmk QoMa <br /> Of r ��_d '/A. , by performing the following work(description of work): <br /> Work will commence on or about. for approximately �'x7 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 ate <br /> E . mmksrER.PM=A0*AENT PEW APPUCA110KDOC(008) <br /> Return Permits to: <br /> CCD <br /> P.O. Box 930 <br /> Stockton, CA 95201-0930 <br />