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APPLICATION FOR ENCROACHMENT PERMIT <br /> PLEASE PRINT: <br /> Date I, ho 1 OFFICE USE ONLY <br /> To: San Joaquin County JOB# � ,�� REF# <br /> Department of Public.Works APN CR# <br /> EXP.DATE 2vl c1 <br /> VALID 3-ID-204i TO /S�Zdl fi DRIVEWAYS: <br /> Pacific Gas & Electric STREETE, <br /> P.O. BOX 930 AREA tti QUAD <br /> TYPE <br /> STOCKTON, CA 95201 FORMS Sg f("o �2R <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 /> PM -z>1c)4,66/,�5 California supplement <br /> Notif. 1075E>--:�13 <br /> The undersigned hereby applies for permission to excavate, construct and/or otherwise encroach on County Highway Right-of-Way on <br /> the iAor44-) side of M t+1E4yel-! P t approximately , feet/Oft <br /> of n by performing the following work(description of work): <br /> ° ° (Il ?� A <br /> Work will commence on or about O for approximately 9 C2 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 /> n. \/3M- <br /> Signature of Applicant-Title Date <br /> E:IP KIMASTERPSIENCROACHMENT PERMIT APPLICATION.DOC(01108) <br /> Return Permits to: <br /> CCD <br /> P.O. Box 930 <br /> Stockton, CA 95201-0930 <br />