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APPLICATION FOR ENCROACHMENT PERMIT <br /> PLEASE PRINT: <br /> Date 5/lel 11 1OFFICE USE ONLY <br /> To: San Joaquin County JOB# S-Z-- REF <br /> Department of Public Works APN _ CR# <br /> EXP.DATE i 2 et <br /> VALID 15' 1 TO. J it DRIVEWAYS: <br /> Pacific Gas & Electric STREETA —T�7— <br /> P.O. BOX 930 AREA QUAD <br /> STOCKTON, CA 95201 TYPE <br /> FORMS Z <br /> 209-942-1627 NOTES <br /> Sketch(Detailed plans may be submitted) <br /> Traff is Control Plan <br /> See attached sketch. shall be as per <br /> current M.U.T.C.D. <br /> California supplement <br /> Noti f. <br /> The undersigned hereby applies for permission to excavate,construct and/or otherwise encroach on County Highway Right-of-Way on <br /> the side of <br /> 0 <br /> off , approximately I feeite <br /> by performing the following work(descriptionofTwork-y <br /> ;s <br /> d <br /> Work will commence on or about for approximately - . <br /> 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 /> \e1•UU�/f lJ f v2 � <br /> Signature of Applicant-Title "" <br /> Date <br /> E.1PU KM4MaU'bl CRacHKENrvERfuraaaucnnOKoee rowel . <br /> Return Permits to: <br /> CCD <br /> P.O. Box 930 <br /> Stockton, CA 95201-0930 <br />