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APPLICATION FOR ENCROACHMENT PERMIT <br /> PLEASE PRINT: <br /> Date OFFICE USE ONLY <br /> To: San Joaquin County JOB# REF# <br /> Department of Public Works APN CR# <br /> EXP. DATE 2 1111-1 <br /> Pacific Gas and Electric Co. VALID 10 TO Z.1111-1 <br /> DRIVEWAYS: <br /> STREET <br /> P.O. Box 930 AREA QUAD NC <br /> Stockton CA 95201 TYPE _ p <br /> ' FORMS <br /> NOTES <br /> (Area Code-Telephone Number) <br /> Sketch (Detailed plans may be submitted) <br /> Traffic Control Plan <br /> See attached sketch. Shall be as per <br /> PM 3090 /353 current M.U.T.C.D. <br /> Notif. lo-T,?L,�oy California supplement. <br /> The undersigned hereby applies for permission to excavate, construct and/or otherwise encroach on County Highway Right-of-Way on <br /> the AIDRTif side of 19e gir"Pa /Zn. approximately A16 7 feet/aiie c.,EST <br /> of /tEn/EFic�C 2/]. /74,4rH0 by performing the following work(description of work): <br /> To eur o,cc G S ��lz vicE <br /> f�E,�h-��i✓�ctT pS�i/i��T �r?=PL�c�rr�1�:�.�T Tv Fv[�dc�. y <br /> Work will commence on or about /v - 1 g -12 for approximately 9y 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 /> 11-1-12 <br /> Signature of Applicant-Title Date <br /> E:IPUBSV.WKIMASTER.PSIENCROACHMENTPERMITAPPLICATION.DOC (01/08) <br />