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APPLICATION FOR ENCROACHMENT PERMIT <br /> PLEASE PRINT: <br /> Date 411 I Z OFFICE USE ONLY <br /> To: San Joaquin County JOB# 706502_ REF# <br /> Department of Public Works APN CR# <br /> EXP.DATE <br /> VALID t 0 / DRIVEWAYS: <br /> Pacific Gas & Electric STREET O 1.G 141/e " <br /> P.O. eox 93o AREA :J'fock1-otj QUAD A/s <br /> TYPE 114 _ -1-7EArw <br /> STOCKTON, CA 95201 FORMS <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.U. <br /> California supplement <br /> PM ' a `� <br /> Notif. itf-b6z)�,lZ <br /> The undersigned hereby applies for permi pion to excavate,construct and/or otherwise encroach on County Highway Right-of-Way on <br /> the ` side of I Nye— approximately 1(�2fl U ' feet/wAs �W <br /> of ' 6e-L-�, by performing the <br /> following work(description of work): <br /> Work will commence on or about 2 Z for approximately Q 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 /> � I )q112 <br /> - <br /> Signature of Applicant-Title Date <br /> E:IP NUMSTERPSIENCROACHMENTPERMITAPPLICATION.DOC(01M) <br /> Return Permits to: <br /> CCD <br /> P.O. Box 930 <br /> Stockton, CA 95201-0930 <br />