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APPLICATION FOR ENCROACHMENT PERMIT <br /> PLEASE PRINT: , O Ms <br /> Date Z OFFICE USE ONLY <br /> To: San Joaquin County JOB# J.?iREF# <br /> Department of Public Works APN CR# <br /> EXP.DATE /5� <br /> VALID g TO 2 /Sj DRIVEWAYS: <br /> Pacific Gas & Electric STREET .%s`n '4✓e. <br /> l AREA oc��oA QUAD G.S <br /> P.O. SOX 930 TYPE 1'eo4'z_- f�T <br /> STOCKTON, CA 95201 i FORMS S�► !s/�vi <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.D. <br /> PM �Z '� I California supplement <br /> Notif. jor,71 <br /> The qndersigned hereby applies for grmission to excavate,construct and/or otherwise encroach on County Highway Right-of-Way o <br /> the side of L►PI ILII approximately Z-A 5 fee h <br /> of n , by performing the following work(description of work): <br /> ` OV, A jgme:h <br /> Work will commence on or about A 1 for approximately Igk2 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 /> 4)11 tea" , / . v9 � ►"+ty_ t5_ 1 l2. <br /> Signature of Applicant-Title Date <br /> E: KWNSTERPSI M0A0*XNT PERWAMMATPON.DOC (01a) - <br /> Return Permits to: <br /> CCD <br /> P.O. Box 930 <br /> Stockton, CA 95201-0930 <br />