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APPLICATION FOR ENCROACHMENT PERMIT <br /> PLEASE PRINT: <br /> Date cp IIZ114- OFFICE USE ONLY <br /> To: San Joaquin County JOB# ,?7__t�C62_l REF# <br /> Department of Public Works APN CR# <br /> EXP.DATE C)-15--2_o 10 <br /> VALID TO DRIVEWAYS: <br /> Pacific Gas & Electric STREET <br /> P.O. BOX 930 AREA �). - QUAD C -- <br /> TYPE <br /> STOCKTON, CA 95201 FORMS <br /> 209-942-1627 NOTES _ r <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 /> PM ;�>108226o-_�5 California supplement <br /> Notif. <br /> The undersigned hereby applies for permission to excavate,construct and/or otherwise encroach on County Highway Right o-Way on <br /> the S side of 1 Pi f1e approximately GZ of feetfs a � <br /> of by performing the following work(description of work): <br /> A4'e— <br /> 0 1 t <br /> Work will commence on or aboutt l t2 for approximately Flo 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 /> un Z/ <br /> Signature of Applicant-Title Date <br /> E:WO MMASTER.PSIENCROACHMENT PERMIT APPLICATION.DOC(01/08) <br /> Return Permits to: <br /> CCD <br /> P.O. Box 930 <br /> Stockton, CA 95201-0930 <br />