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APPLICATION FOR ENCROACHMENT PERMIT <br /> PLEASE PRINT: <br /> Date 1 n/f I /!3 OFFICE USE ONLY <br /> To: San Joaquin.County JOB# REF# <br /> Department of Public Works APN CR# <br /> EXP.DATE t, Is a <br /> VALID i ) TO ,2 3 DRIVEWAYS: <br /> Pacific Gas & Electric STREET VSr.),MAkt A <br /> P.O. BOX 930 AREA S-rOnkMij QUAD <br /> TYPE X.6l_C <br /> STOCKTON, CA 95201 FORMS Sts w !fitc4 a ,' <br /> 209-942-1627 NOTES <br /> a�tE 67B afmg <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 /> Noti f. <br /> The undened hereby applies for permission to excavate, construct and/or otherwise encroach on County Highway Right-of-Way on <br /> rsig <br /> the 0Lt�uidAof bc)21a5 ( nyVl�c /1 approximately feet/mile <br /> of by performing the following work(description/of work): <br /> Work will commence on or about 10/111/ for approximately 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 /> c <br /> IYI z <br /> Signature of Applicant-Title Qlate <br /> E:IPU . KIMASTER.PSIENCROACHMENTPERMITAPPLICATION.DOC (01108) <br /> Return Permits to: <br /> CCD <br /> P.O. Box 930 <br /> Stockton, CA 95201-0930 <br />