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PLEASE PRINT: APPLICATION FOR ENCROACHMENT PERMIT <br /> . <br /> Date <br /> To: San Joaquin County OFFICE USE ONLY <br /> Department of Public Works JOB# X5-a_ REF# <br /> APN <br /> EXP.DATE CR# <br /> Pacific Gas A Electric i VALID E, <br /> STREET <br /> Z DRIVEWAYS: <br /> P.O. BOX 930 <br /> AREAUAD <br /> STOCKTON; CA 95201 I TYPE <br /> v <br /> 209-942-1627 FORMS Ii NOTES21 <br /> ,I <br /> [Notif. <br /> led plans may be submitted) <br /> Traffic Control Plan <br /> ached sketch, shall be as per <br /> current M.U.T.C.p. <br /> & <br /> -76&7 California supplement <br /> 1052%/ <br /> The undersi ed hereby applies for permission to excavate,construct and/or otherwise encroach on Count Highway the side of <br /> of approximately�` y g way Right-of--Way on <br /> feet�iis–�2t1.�'�j <br /> by performing the following work(description of work): <br /> `Work will commence on or about - <br /> for approximately p <br /> 17 <br /> I,the undersigned,certify that I am the owner of the respective property,or am qualified to represent the own days. <br /> 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 an <br /> d approval. <br /> 1; A � tY / <br /> Signature of Applicant-Title — Zw 1 <br /> E"PU . KNA"'P,P"ENCROACHMENTPERtATAPPLICATION.DOC (01N8) Dat <br /> Return Permits to: <br /> CCD <br /> P.O. Box 930 <br /> Stockton, CA 95201-0930 <br />