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APPLICATION FOR ENCROACHMENT PERMIT <br /> PLEASE PRINT: <br /> r <br /> Date ��� Z� , �L — OFFICE USE ONLY <br /> To: San Joaquin County JOB# ► TIcc -z_ REF# <br /> Department of Public Works APN CR# <br /> EXP.DATE G—T—201 y <br /> VALID _— 2O1ctTO C^1—ZUlu DRIVEWAYS: <br /> Pacific Gas and Electric Co. STREET <br /> P.O. Box 930 AREA <br /> TYPE <br /> Stockton, CA 95201 FORMS <br /> NOTES <br /> - <br /> Area Code-Telephone dumber) <br /> Sketch(Detailed plans may be submitted) <br /> Traffic Control Plan <br /> See attached sketch. Shall be as per <br /> PM -3(C)6rZ<)4t current M.U.T.C.D. j <br /> Notif. 10-7r3ZGZ California supplement. <br /> Please return permit to: <br /> CCD Desk <br /> 4040 West Lane <br /> Stockton, CA 95204 <br /> I • <br /> I <br /> The undersigned hereby appliessfforpermission to excavate,construct and/or otherwise encroach on County Highway Right-of-Way on <br /> the E side of �l (.{FLNIG� AVE . approximately �?r feet/ a ouT <br /> of , :f��rj 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 /> wor bed above in accordance with the rules and regulations of San Joaquin County and subject to inspection and approval.. <br /> Z- r <br /> Signature of Applicant-Tie Date �— <br /> E:IPUBdV.WMMASTER.PSIENCROACHMENTPERMRAPPLICATION.DDC (0110a) <br />