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APPLICATION FOR ENCROACHMENT PERMIT <br /> PLEASE PRINT: <br /> Date t I I i� OFFICE USE ONLY <br /> To: San Joaquin County JOB# REF# <br /> Department of Public Works APN CR# <br /> EXP.DATE / <br /> VALID 11116- <br /> /Z3 TO / / DRIVEWAYS: <br /> Pacific Gas & Electric STREET c Q Vu <br /> P.O. BOX 93O AREA J_<9e QUAD <br /> TYPEdt <br /> STOCKTON, CA 95201 FORMS 2q <br /> 209-942-1627 NOT ES <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 /> PM 4 I"�?5?17�7 California supplement <br /> Notif. <br /> The undersi ned hereby applies for permission to excavate,construct and/or otherwise encroach on County Highway Right-of-Way on <br /> the 50side of �' OflJtn approximately 8e> feet/laage <br /> of e er ha'DGIL�-o�, by performing the following work(description of work): <br /> Work will commence on or about 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 /> Un, \&J Uwu. , 1Y 6v2 <br /> E:j1Signature of Applicant-Title Date <br /> ASTER.PSENCROACHMENT PERMIT APPLICATION.00C (01108) <br /> Return Permits to: <br /> CCD <br /> P.O. Box 930 <br /> Stockton, CA 95201-0930 <br />