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APPLICATION FOR ENCROACHMENT PERMIT <br /> PLEASE PRINT: / <br /> Date OFFICE USE ONLY <br /> To: San Joaquin County JOB# FW72COC2- ( REF# <br /> Department of Public Works APN CR# <br /> EXP.DATE /_ 2'�>/14 <br /> VALID G-S20 V TO - 1.-V 1 DRIVEWAYS: <br /> Pacific Gas & Electric STREET <br /> P.O. BOX 930 AREA OAl QUA <br /> TYPE 8gAVX"'t01' <br /> STOCKTON, CA 95201 FORMS SS/wLA_�! fZZ-1 Tno c_1,,_ <br /> 209-942-1627 NOTES <br /> Sketch(Detailed plans may be submitted) <br /> Troff is Control Plan <br /> shall be as per <br /> See attached sketch, current M.U.T.C.D. <br /> PM 4Zo53132 California supplement <br /> Notif. <br /> The undersiped hereby applies for permi sion oto excavate, construct and/or otherwise encroach on County Highway Right-of-Way on <br /> 5 <br /> the_ 0041—) side of o r' QG h, approximately 175 feet/mile <br /> Of V t��`i1Fi } ,�l� l _ by performing the followingwork(description of work): <br /> C LA-Dor immanent- <br /> J <br /> Work will commence on or about !� _for approximately14'11 <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 /> Signature of Applicant-Title Date <br /> E:IPU KIMASTER.PSIENCROACHMENT PERMIT APPIICATIONDOC (01108) <br /> Return Permits to.- <br /> CCD <br /> o:CCD <br /> P.O. Box 930 <br /> Stockton, CA 95201-0930 <br />