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APPLICATION FOR ENCROACHMENT PERMIT <br /> PLEASE PRINT: <br /> Date I OFFICE USE ONLY <br /> To: San-Joaquin Count �ci REF# <br /> Y JOB# _ <br /> Department of Public Works APN _ CR# <br /> EXP.DATE S t 1 <br /> VALID SC) 13 TO 0(1113. DRIVEWAYS: <br /> Pac if is Gas & Electric STREET r <br /> AREA QUAD J�9S <br /> P.O. BOX 930 TYPE L' 4 oto <br /> STOCKTON, CA 95201 FORMS <br /> 209-942-1627 NOTES of <br /> 09 <br /> Sketch(Detailed plans may be submitted) <br /> Traff is Control Plan <br /> shall be as per <br /> See attached sketch. current M.U.T.C.D. <br /> California supplement <br /> PM� ��•OtJ'o <br /> Notif. 1oC&4(PI76o <br /> The undersi ned hereby applies for permission to excavate,construct and/or otherwise encroach on County Highway Right-of-Way <br /> �on <br /> the V side of NlI ftA4'' }' approximately JZ' feet/ake IVOm <br /> of d . ,_ }�� by performing the following work(description ofwork):: <br /> rh <br /> Work will commence on or about for approximately V�2 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:IPU MMASTERPSIENCROACHMENTPERMIT APPI-ICATION.DOC (01/06) <br /> Return Permits to: <br /> CCD <br /> P.O. Box 930 <br /> Stockton, CA 95201-0930 <br />