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APPLICATION FOR ENCROACHMENT PERMIT <br /> PLEASE PRINT: <br /> Date ��� Z I OFFICE USE ONLY <br /> To: San Joaquin County JOB# V tAff 15,00,52,/ REF# <br /> Department of Public Works APN CR# <br /> EXP.DATE —I— Zb 1 Z" <br /> VALID !— S-ZyIZTO T— 1 -2y12- DRIVEWAYS: <br /> Pacific Gas & Electric STREET <br /> P.O. BOX 930 AREA Lttldei- QUAD N f <br /> TYPE <br /> STOCKTON, CA 95201 i FORMS ,.SS/'Wa <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.O. <br /> PM California supplement <br /> Notif. <br /> The undersigned hereby applies for permission to excavate, construct and/or otherwise encroach on County Highwa Right-of-Way on <br /> the 6FJ l�+- side of `rl approximately. 2.25 ' fee mill > <br /> of ' by perfoffning the following work(description of work): <br /> d <br /> i9 <br /> Work will commence on or about Ifor approximately i 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 /> 6&169 6+by- <br /> A <br /> Signature of Applicant-Title ate <br /> E:1PU KIAdASTER.PSIENCROACHMENTPERMITAPPLICATION.DOC(0108) <br /> Return Permits to: <br /> CCD <br /> P.O. Box 930 <br /> Stockton, CA 95201-0930 <br />