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APPLICATION FOR ENCROACHMENT PERMIT <br /> PLEASE PRINT: ,� h <br /> Date �V/�� y <br /> ly/I II OFFICE USE ONLY <br /> To: San Joaquin County JOB# 5M.4 REF# <br /> Department of Public Works APN CR# <br /> EXP.DATE S/S 12, <br /> VALID lthdll 0DRIVEWAYS: <br /> Pacific Gas & Electric STREET <br /> P.O. BOX 930 1 AREA —7&:nkg y QUAD P11151 <br /> TYPE lY " <br /> STOCKTON, CA 95201 FORMS <br /> 209-942-1627 NOTES <br /> I <br /> Sketch(Detailed plans may be submitted) <br /> Traffic Control Plan <br /> shall be as per j <br /> See attached sketch. current M.U.T.C.p. <br /> California supplement <br /> PMA, 571� <br /> Notif. <br /> The undersi nedhereby applies for permission to excavate,construct and/or otherwise encroach on County Highway Right-of-Way on <br /> the side of a proximately (U' feeffmite <br /> of ,by performing the following work(descripti of work): <br /> Work will commence on or about ZZ11 I for approximately BO 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 /> ui) \136D 112 <br /> Signature of Applicant-Title Date <br /> E1P STWSOCROACHLIMTPMWAPfUCATION.DOC(01108) <br /> Return Permits to: <br /> CCD <br /> P.O. Box 930 <br /> Stockton, CA 95201-0930 <br />