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APPLICATION FOR ENCROACHMENT PERMIT <br /> PLEASE PRINT: <br /> Date I /�� �2- OFFICE USE ONLY <br /> To: San Joaquin County JOB# REF# <br /> Department of Public Works APN CR# <br /> EXP.DATE / _ <br /> VALID 0 �/ DRIVEWAYS: <br /> Pac if is Gas & Electric STREET <br /> AREA ;�,.r,,/ QUAD <br /> F <br /> P.O. BOX 930 TYPE ,04--4'_-hoz <br /> STOCKTON, CA 95201 FORMS 55/svy, <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 /> California supplement <br /> PM 5Cfl582A '4 <br /> Notif. 1 254"1-52 <br /> The undersigned hereby applies for permission to excavate, construct and/or otherwise encroach on County Highway Right-of-Way on <br /> the side of �z. V approximately l feeV=k Wo- <br /> of L.GY—V .e2 Lc l by performing the following work(description of work): <br /> r � <br /> Work will commence on or about l for approximately i 80 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 /> Signature of Applicant-Title Date <br /> E:N( . MMASTER.PSIENCROACHMENT PERMIT APPLICATION.DOC (01108( <br /> Return Permits to: <br /> CCD <br /> P.O. Box 930 <br /> Stockton, CA 95201-0930 <br />