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APPLICATION FOR ENCROACHMENT PERMIT <br /> PLEASE PRINT: <br /> Date 'Q '2�%' ,�-z- OFFICE USE ONLY <br /> To: San Joaquin County JOB# 73465'a—G REF# <br /> Department of Public Works APN CR# <br /> EXP.DATE 5/ /3 <br /> VALID d 2 2 0 S/&3 DRIVEWAYS: <br /> Pacif is Gas & Electric STREET NT ,QaS YE, <br /> P.O. BOX 930 AREA do o►.J QUAD tg <br /> STOCKTON, CA 95201 TYPE LL htoLP <br /> FORMS wh7 ,2-29 ?r�ncAe <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 California supplement <br /> NOtlf. <br /> The undersigned hereby applies for permission to excavate,construct and/or otherwise encroach on County Highway Right-of-Way on <br /> ofe —side of .� approximately �U feet/ Ic <br /> __ <br /> by performing the following work(description ooTw'ork): <br /> c:J p <br /> Work will commence on or about I r? c- 17, for approximately ! o 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 /> \"'� o a" , * 11) z Z- <br /> Signature of Applicant-Title Date <br /> E:IPU& MMASTER.PSIENCROACHMENT PERMIT APPLICATION.DOC(01108) <br /> Return Permits to: <br /> CCD <br /> P.O. Box 930 <br /> Stockton, CA 95201-0930 <br />