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PLEASE PRINT: APPLICATION FOR ENCROACHMENT PERMIT <br /> Date <br /> To: San Joaquin County OFFICE USE ONLY <br /> Department of Public Works JOB# �3f2-� REF# <br /> APN <br /> EXP.DATE CR# <br /> Pacific Gas & Electric VALID f i� TO 3 fi <br /> STREET r' DRIVEWAYS: <br /> P.O. BOX 930 OLAC�aq <br /> TYPE o, QUAD �1 <br /> STOCKTON, CA 95201 1-�- a� P-11.-"209-942-1627 FORMS SS �rys .��2�1 <br /> NOTES <br /> Sketch(Detailed plans may be submitted) <br /> Traffic Control Plan <br /> See attached sketch. shall be as per <br /> current M.U.T.C.p. <br /> PMCalifornia supplement <br /> Notif. io1155 <br /> Z7,, <br /> '��or� to ire cw'or►e on �a-�v,�d4� ct�z3�i2 <br /> Chic �a S o�Gon�l/��� dur�r�5 Ike <br /> The undersigned hereby applies for permission to excavate,construct and/or otherwise encroach the side of <br /> of h on County Highway Right-of--Way on <br /> approximately lG;d. feetlafe /.��— <br /> by performing the foil wing work descripti nAof work): <br /> Work will commence on or about <br /> I,the undersigned,certify that I am the owner of the respective pro ert for approximately <br /> days. <br /> Py,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� ct to inspection and approval. <br /> Naabawu • /K <br /> Signature of Applicant-Title �� 8 <br /> UP KIMASTER.PSIENCROACHMEM Date <br /> PFRMI7APP�ICA710N.DOC(0110S) <br /> Return Permits to: <br /> CCD <br /> P.O. Box 930 <br /> Stockton, CA 95201-0930 <br />