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APPLICATION FOR ENCROACHMENT PERMIT <br /> PLEASE PRINT: <br /> Date ' I OFFICE USE ONLY <br /> To: San Joaquin County JOB# 7 5240TZ-4 REF# <br /> Department of Public Works APN a A CR# <br /> EXP.DATE 11hh3 <br /> VALID j 03 DRIVEWAYS: <br /> Pac i f is Gas & Electric STREET11, 4 <br /> AREA /' QUAD <br /> ple- <br /> P.O. BOX 930 � TYPED1�S <br /> STOCKTON, CA 95201 FORMS qg& Z <br /> 209-942-1627 NOTES <br /> Iry 00 <br /> Sketch(Detailed plans may be submitted) <br /> Traf f is Control Plan <br /> shall be as per <br /> See attached sketch. current M.U.T.C.D. <br /> California supplement <br /> Noti f. <br /> The undersi ned hereby applies for permission to excavate, construct and/or otherwise encroach on County Highway Right-of-Way on <br /> the t4 4 side of approximately <br /> of �,��aj)o pp Y feet/ <br /> , by performing the following work(description of work): <br /> - or V, <br /> Work will commence on or about for approximately Jtdays. <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 KIMASTER.PSIENCROACHMENTPERMIT APPLICATION.DOC(01/08) <br /> Return Permits to.- <br /> CCD <br /> o:CCD <br /> P.O. Box 930 <br /> Stockton, CA 95201-0930 <br />