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APPLICATION FOR ENCROACHMENT PERMIT <br /> PLEASE PRINT: <br /> Date 1/_ 1 — OFFICE USE ONLY <br /> To: San Joaquin County JOB# 79m5 , REF# <br /> Department of Public Works APN CR# <br /> EXP. DATE i <br /> Pacific Gas and Electric Co. <br /> VALID to TO tt t3 ii DRIVEWAYS: <br /> STREET 1,=Aeas7TA6,f e2E) <br /> P.O. BOX 930 AREA QUAD Al,— ' <br /> Stockton. CA 95201 TYPE <br /> FORMS <br /> NOTES <br /> (Area+erode-Telephone Number) <br /> Sketch(Detailed plans may be submitted) <br /> Traffic Control Plan <br /> See attached sketch. Shall be as per <br /> PM -3 r `�, , �,'t 't � current M.U.T.C.D. <br /> Not if. i o x 31 '7 <6 1.7 California supplement. <br /> The undersigned hereby applies for permission to excavate,construct and/or otherwise encroach on County Highwa Right-of-Way on <br /> the T•4.3 _side of HW 4 1z? l=r�,�,�.5 e ,;12 approximately el3 z e 'mile IU <br /> of 5 k 'n .r .� ���t/10ii4a(,� , by performing the following work escription of work): <br /> de-Xr- �0 <br /> Work will commence on or about 1 D z // for approximately 3 n days. <br /> I,the undersigned, -ertify 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 /> f/7 �1 <br /> Signature of Ap nt-Tit --- Date <br /> E'IPUB-SV.WMMASTER.PSIENCROACFI',:ENT PERMIT APPLICATION.DOC (0101) <br />