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APPLICATION FOR ENCROACHMENT PERMIT <br /> PLEASE PRINT: <br /> Date Q 12 l Z OFFICE USE ONLY <br /> To: San Joaquin County JOB# fi` a-f REF# <br /> Department of Public Works APN CR# <br /> EXP.DATE ,�t 3`�3 <br /> VALID 7-_ DRIVEWAYS: <br /> Pacific Gas & Electric STREET ! <br /> P.O. BOX 930 AREA X73 — QUAD <br /> -STOCKTON, CA 95201 TYPE <br /> FORMS �,� <br /> 209-942-1627 NOTES f <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.O. <br /> PM 3,5)9 5 50'74, California supplement <br /> Notif. <br /> The undersigg,ned hereby applies for permission to excavate,construct and/or otherwise encroach on County Highway Right-of-Way on <br /> the �0.�♦ sideof A4)+&n2z Pa, 4 approximately 120 feet/w* Wcr_k� <br /> of f IlGr-Pa1G1 w}nGV—+nI , by performin the following work(description of work): <br /> t1 ho -� {V(G� uJh i Lh I 5 oxzA af Gh <br /> Lo os <br /> Work will commence on or about t7 7— 1'Z for approximately 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 /> f� . �t�� �h 4r 0 12 I I Z <br /> fS_i�gna,ture of Applicant-Title Da e <br /> EP.PSIECROACNMENT PERMIT APPLICATION.DOC (01108) <br /> Return Permits to: <br /> CCD <br /> P.O. Box 930 <br /> Stockton, CA 95201-0930 <br />