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1 <br /> APPLICATION FOR ENCROACHMENT PERMIT <br /> PLEASE PRINT: <br /> Datelid _ OFFICE USE ONLY <br /> To: San Joaquin County JOB# REF# <br /> Department of Public Works APN CR# <br /> EXP.DATE <br /> Pacific Gas&Electric Comm, PG&E VALLA 'j8li Iz TO /o i 2 DRIVEWAYS: <br /> (Applicant Name) STREET <br /> ARTA f.0-29QUAD <br /> 85.0 StlliWater EW _ TYPE 6 c '�C.rt�.i ` <br /> (Mailing Address) FORMS <br /> NOTES <br /> West Sacramento,CA 9560 <br /> (City,State,Zip Code) <br /> .9.1 1&7A0_1 ftL <br /> (Area Code-Telephone Number) <br /> Sketch(Detailed plans may be submitted) <br /> PIK 3089 73 _� l <br /> The undersigned hereby applies for permission to excavate,construct and/or otherwise encroach on County Highw Right-of-Way o l <br /> the <br /> slde of �i� r�iGE,�� approximately i3 0 e�t� j=�1 <br /> of by performing the following work(description of work): <br /> P];qgse refer to constrUgWn drawings for work locations. <br /> PG&E will ie replacing i' - oles, equipment <br /> and re iP acing"movingiinstaning mown g v, as rje juired. <br /> Work will commence on or about . / z for 40proximately O 72Z days. <br /> J,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 /> wo s ed above In aoc ce with the rules and regulalions of San Joaquin County and subject to Inspection and approval. <br /> el <br /> 2.- <br /> ign tore of Applicant-Tale i)ate <br /> Ewesyxxgaste+rs,�mo�auotrrewikflictriartooc pot! . <br />