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APPLICATION FOR ENCROACHMENT PERMIT <br /> PLEASE PRINT:Q <br /> Date 1 f I CI /15 OFFICE USE ONLY <br /> - - - - -JOB# - - REF# <br /> -To: San Joaquiri County - � 3� <br /> Department of Public Works APN CR# <br /> EXP.DATE Wills <br /> VALID T i t DRIVEWAYS: <br /> Pacific Gas & Electric STREETu rSr <br /> AREA eA&p% D QUAD /19 <br /> P.O. Box 930 TYPE -?ALL <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 Flo 12411 -7 <br /> Notif. <br /> The LLindersigned hereby applies for permission to xcavate,construct and/or otherwise encroach on County Highway Right-of-Way on <br /> the QC side of Qr,'-'h approximately 15-7' feet/mAe— to <br /> of 1. r' by performing the following work(description of work): <br /> 12)&47 GhvrGh ��— <br /> Work will commence on or about for approximately 00 days. <br /> Ar <br /> I,the undersigned,certify that I am the owner of the respective properly,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 /> \Ilbawu , 6111 � <br /> Signature of Applicant-Title Date <br /> E]P KWASTERPSVENCROACHMENT PERMIT APPLICATION.DOC(01108) <br /> Return Permits to: <br /> CCD <br /> P.O. Box 930 <br /> Stockton, CA 95201-0930 <br />