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APPLICATION FOR ENCROACHMENT PERMIT <br /> PLEASE PRINT: <br /> Dated 1-7111 <br /> OFFICE USE ONLY <br /> To: San Joaquin County JOB# 73 O�Z_4 REF# <br /> Department of Public Works APN -23,,�, CR# <br /> EXP.DATE -t --2.j t Z <br /> VALID --x�-23 Z� o To X�2 DRIVEWAYS: <br /> Pacific Gas & Electric STREET fib. Ct't�. Ave- <br /> P.O. BOX 930 AREA S+60. h QUAD <br /> TYPE <br /> STOCKTON, CA 95201 FORMS <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.b. <br /> PM California supplement <br /> Notif. t : ! --5] <br /> The unde r-sigpqa hereby applies for permission to excavate,construct and/or otherwise encroach on County Highway Right-of-Way on <br /> Of �, side of d _approximately V a5 feet/Bak <br /> by performin the following work(descriptiAL D-Lc <br /> on of work): <br /> ff - <br /> Work will commence on or about_ fora roximatel <br /> PP y- rye 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 /> a� <br /> Signature of Applicant-Title Dat—e <br /> EMU NIMASTE"SENUkOACHkORPSWAPPl1CA'nON.DOC (01178) <br /> Return Permits to: <br /> CCD <br /> P.O. Box 930 <br /> Stockton, CA 95201-0930 <br />