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APPLICATION FOR ENCROACHMENT PERMIT <br /> PLEASE PRINT: <br /> Date Z ' I OFFICE USE ONLY <br /> To: San Joaquin County JOB# W .73CX,52- REF# <br /> Department of Public Works APN 1 (4 O—C( CR# <br /> EXP.DATE 3--1 2e3t 2 <br /> VALID^2�T�2d►� TO ,�-1 —2 9 2 DRIVEWAYS: <br /> Pacif is Gas & Electric STREETI tC> v� A v <br /> P.O. BOX 930 AREA j�{ OUAD _ <br /> TYPE ll 14,1 <br /> STOCPGTON, CA 95201 <br /> FORMS <br /> 209-942-1627 NOTES <br /> Sketch(Detailed plans may be submitted) <br /> Traff is Control Plan <br /> shall be as per <br /> See attached sketch. current M.U.T.C.D. <br /> California supplement <br /> o4b* <br /> Notif. lf)eAC)IQA <br /> The ndersi ned hereby applies fpr perp'ssion to excavate,construct and/or otherwise encroa h on County Highway Right-of-Way on <br /> the -side of _ approximately l� fee <br /> Of t cT d!. , by performing the following work(description of work): <br /> �. <br /> Work will commence on or about A.120 111 for approximately 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 /> 17-7,111 <br /> Signature of Applicant-Title ate <br /> E: CMACH*M PEW APPUCKnOKDX PIM - <br /> Return Permits to: <br /> CCD <br /> P.O. Box 930 <br /> Stockton, CA 95201-0930 <br />