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APPLICATION FOR ENCROACHMENT PERMIT <br /> PLEASE PRINT: <br /> Date 511-04, OFFICE USE ONLY <br /> To: San Joaquin County JOB# REF# <br /> Department of Public Works APN CR# <br /> EXP.DATE <br /> VALID cs^1 — TO —&26Ic� DRIVEWAYS: <br /> Pacific Gas & Electric STREET M%55101A, Avg <br /> P.O. BOX 930 AREA Y�QUAD CC <br /> TYPE <br /> STOCKTON, CA 95201 FORMS t,J Q <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 �)I v?IXM <br /> Notif. <br /> The undersigned hereby applieL�s f99r permission to excavate,construct and/or otherwise encroach on County Highway Bight-of-Way on <br /> the side of Mt6 Ion P�vL approximately I Do feet/r <br /> of VG 114 A t%.V. I - Z. i-% , by performing the followin work(description of work <br /> LLII I �G. <br /> Loa 4o 4i>116&)2 <br /> Work will commence on or about for approximately 124> 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 /> Q[JM "OM a12 +,�r 5� IZI 14- <br /> Signature of Applicant-Title Date <br /> E:IP . NIMASTER.PSIENCROACHMENTPERUTAPPLICATION.DOC (01/08) <br /> Return Permits to: <br /> CCD <br /> P.O. Box 930 <br /> Stockton, CA 95201-0930 <br />