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PLEASE PRINT: APPLICATION FOR ENCROACHMENT PERMIT <br /> Date <br /> OFFICE USE ONLY <br /> To: San Joaquin County <br /> Department of Public Works JOB# j�}'DDSZ-� REF# <br /> APN — <br /> EXP.DATE CR#VALID <br /> �, <br /> Pacific Gas & Electric STREET )I <br /> TO i� DRIVEWAYS: <br /> P.O. BOX 930AREA <br /> STOCKTON, CA TYPE QUAD <br /> ^ _ <br /> 95201 <br /> 209-942-1627 FORMS <br /> NOTTEE S <br /> Sketch(Detailed plans may be submitted) <br /> Traffic Control Plan <br /> See attached sketch. shall be as per <br /> current M.U.T.C.p. <br /> PMS ` California supplement <br /> Notif. � I <br /> The un ersigned hereby applies for permission to excavate cst <br /> the side of rucf and/or otherwise encroach on Count Hi <br /> "-� <br /> of 'r � approximate) Y Highway Right-of-Way on <br /> Y '1 C feet/re= l <br /> berFormmg the following work(description of work): <br /> Work will commence onor about <br /> for annrnYlm�+o(,iy _ <br /> rr �• nuwdays. <br /> the undersigned,certify that I am the owner of the respective property,or am qualified to represent the owner <br /> and agree to do the <br /> p <br /> work described above in accordance with the rules and regulations of San Joaquin County and subject to inspection on and approval. <br /> JSignature of Applicant-Title a� <br /> EAPUKWASTERPSIENCROACH Date <br /> MENT PERgT APPLICATION.OCC (01A8J <br /> Return Permits to: <br /> CCD <br /> P.O. Box 930 <br /> Stockton, CA 95201-0930 <br />