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Y <br /> APPLICATION FOR ENCROACHMENT PERMIT <br /> PLEASE PRINT: <br /> Date -4 I OFFICE USE ONLY <br /> To: San Joaquin County JOB# REF# <br /> Department of Public Works APN CR# <br /> EXP.DATE <br /> VALID g�p TOhI <br /> L DRIVEWAYS: <br /> Pacific Gas & Electric STREET Z.Or,4 WM6665-45; <br /> AREA C/ hI QUAD 105 <br /> P.O. BOX 930 TYPE <br /> STOCKTON.' CA 95201FORMS 12U. <br /> 209-942-1627 ,NOTES !! <br /> Sketch(Detailed plans may be submitted) <br /> Traffic Control Plan <br /> s hal I be as per <br /> See attached sketch. current M.U.T.C.D. <br /> PM 41?2-7�601 California supplement <br /> Notif. I C6zs6'1814- <br /> The undersigned hereby applies for permission to excavate,construct and/or otherwise encroach on County Highway Right-o-Way on <br /> the side of L-� A-4a4 C-1.1 approximately Im feet/ <br /> of 1 1 h44--rrO � , by performing the following work(description of work): <br /> 1L <br /> o. <br /> Work will commence on or about for approximately [60 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 /> \0YJr <br /> Signature of Applicant-Title ate <br /> E:IPU KIMASTER.PSIENCROACHMENT PERMIT APPLICATION.DOC (01/08) <br /> Return Permits to: <br /> CCD <br /> P.O. Box 930 <br /> Stockton, CA 95201-0930 <br />