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APPLICATION FOR ENCROACHMENT PERMIT <br /> PLEASE PRINT: <br /> Date AI &A-4— OFFICE USE ONLY <br /> To: _=San Joaquin_County =_- -_ JOB# <br /> Department of Public Works APN _ CR# <br /> EXP.DATE <br /> Pacific Gas and Electric Co. VALID �- 201 TO `�—1—Z v t� DRIVEWAYS: <br /> STREET <br /> P.®. ®X 930 AREA , CLAD _ <br /> Stockton, CA 05201 TYPE <br /> FORMSJN1�r2(� <br /> NOTES <br /> ("(Area Code�Telephone Number) - ' <br /> _14�ZL_ <br /> Sketch(Detailed plans may be submitted) <br /> " 1 <br /> Traffic Control Plan <br /> See attached sketch. ;, Shall be as per <br /> PMjQ��1 ,r i current M.U.T,C.D. <br /> Notif.t��R California supplement. <br /> • I <br /> • ��E �Tue.�J �.�IIT �.: <br /> The undersigned hereby applies f r permission to excavate, construct and/or otherwise encroac ori County Highway Right of- on <br /> the side approximately feetl �� <br /> of _ z by performing the f lowin wPo <br /> �es,n tion of Work). <br /> - <br /> Work , <br /> Work will commence on or about for'approximately days. <br /> Y <br /> I,the and si ned,certify.that I am the owner of the respective property,or am qualified to represent the owner and agree to do the <br /> wor escri d above in accordance with the rules and regulations of San Joaquin County and subject to inspection and approval.. <br /> Signature of Applicant a Title Date <br /> E:WB-SV.WKIMASTER.PS(ENCROACHMENTPERMITAPPUCATION.DOC C07/04 <br /> Please return permit to: <br /> CCD Desk <br /> 4040 West Lane <br /> Stockton,CA 95204 <br />