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APPLICATION FOR ENCROACHMENT PERMIT <br /> PLEASE PRINT: <br /> Date OFFICE USE ONLY <br /> To: San Joaquin County JOB# 73 06S7—Ko REF# <br /> Department of Public Works APN CR# <br /> EXP.DATE / L <br /> VALID T L DRIVEWAYS: <br /> Pacific Gas & ElectricSTREET c r11�.e <br /> AREAe' QUAD $W <br /> P.O. BOX 930 TYPE ' <br /> STOCKTON, CA 95201 i FORMS <br /> 209-942-1627 NOTES <br /> I <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.D. <br /> California supplement <br /> PM <br /> Notif. <br /> The un ersigned hereby applies� fo�r p'e�rmi�cion to excavate,construct and/or otherwise encroach on County Highway Right-of-Way on <br /> the V &�+ sideof_ NId�1�� 1Jr approximately 5-Et�-fl feetlmiie <br /> of 1 / ,by performing the following work(description of work): <br /> + C& , <br /> Work will commence on or about 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 /> Signature of Applicant-Title ate <br /> E: MAM"S%ENCROA0MNf PERWAPPUW0N.DX(OM) <br /> Return Permits to: <br /> CCD <br /> P.O. Box 930 <br /> Stockton, CA 95201-0930 <br />