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APPLICATION FOR ENCROACHMENT PERMIT <br /> PLEASE PRINT: <br /> Date 5 1121 1.4- OFFICE USE ONLY <br /> To: San Joaquin County JOB# _] Z-6 REF# <br /> Department of Public Works APN CR# <br /> EXP.DATEZd1 <br /> VALID .2(j TO /S 2U►c� DRIVEWAYS: <br /> Pacific Gas & Electric <br /> STREET l�Otkt�� S <br /> P.O. BOX 930 AREA QUAD <br /> �- <br /> TYPE <br /> STOCKTON, CA 95201 FORMS >a <br /> 209-942-1627 NOTES <br /> Sketch Detailed plans may be submitted) <br /> ( p Y <br /> Traffic Control Plan <br /> shall be as per <br /> See attached sketch. current M.U.T.C.D. <br /> California supplement <br /> PM A'LI 1"1Z(o8 <br /> Notif. <br /> The undersigned hereby applies for permission to excavate,construct and/or otherwise encroach on County Highway Right-of-Way on <br /> the !!50LVT1h side of h approximately 2'15 feet/mi�e <br /> of C CAInaI 6�• IG-bn by performing the following work(description of work): <br /> 2= W +0 r yr ll . 4z%0VkA .516114 <br /> C'r <br /> Work will commence on or about 5151 Ihe for approximately 01 D 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 /> 51 I-L11 4- <br /> Signature of Applicant-Title Date <br /> E SPU MMASTER.PSIENCROACHMENT PERMIT APPLICATION.00C (01108) - <br /> Return Permits to: <br /> CCD <br /> P.O. Box 930 <br /> Stockton, CA 95201-0930 <br />