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APPLICATION FOR ENCROACHMENT PERMIT <br /> PLEASE PRINT: <br /> Date U115 OFFICE USE ONLY <br /> To: San Joaquin County JOB# REF-# <br /> Department of Public Works APN CR# <br /> EXP.DATE Of 9 <br /> VALID !5 0 YN_13 DRIVEWAYS: <br /> Pacific Gas & Electric <br /> STREET * <br /> AREA QUAD l <br /> P.Q. BOX 930 TYPE <br /> STOCKTON, CA 95201 FORMS <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 <br /> Notif. ti,�26Z_5507 <br /> The undersigned hereby applies f r permission to excavate,construct and/or otherwise encroach on County Highway Right-o1f-,WI, on <br /> theyAor side of V, PAY, approximately �o feet/e& s <br /> of G , by performing the following work(description of work): <br /> Work will commence on or about for approximately t8cp days. <br /> IV <br /> 1,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 /> _4Aq. &J v 6'a" - <br /> _L 41)5 <br /> Signature of Applicant-Title NO <br /> E:1PU . MMASTERPSIENCROACHMENTPERMIT APPLICATION.DOC (01/08) <br /> Return Permits to: <br /> CCD <br /> P.O. Box 930 <br /> Stockton, CA 95201-0930 <br />