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APPLICATION FOR ENCROACHMENT PERMIT <br /> PLEASE PRINT: c <br /> Date 5 t}51 14- OFFICE USE ONLY <br /> To: San Joaquin County JOB# 7300 j Z REF# <br /> Department of Public Works APN CR# <br /> EXP.DATE t ( i t 4- <br /> VALID 7/1/LV TO l ( (/(¢ DRIVEWAYS: <br /> Pacific Gas & Electric STREET 'S (LT qga� Rca <br /> P.O. BOX 930 AREAt4P�-� C4 QUAD �_ <br /> TYPE <br /> STOCKTON, CA 95201 FORMs /!•t/�� -z9 <br /> 209-942-1627 NOTES <br /> Sketch(Detailed plans may be submitted) <br /> Traff is Control Plan <br /> shall be as per <br /> See attached sketch. current M.U.T.C.D. <br /> California supplement <br /> PM84�l 53 <br /> Notif. <br /> The undersi ned hereby applies for permission to excavate, construct and/or otherwise encroach on County Highway Right-of-Way on <br /> the side of hl approximately 710' feet/mile 1,4DOh_ <br /> of o by performing the following work(description of work): <br /> q-� --XrtILCe— a� 6. <br /> Work will commence on or about for approximately Zo 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 /> \Oyj ,j <br /> " - J�r 6A/j t;�5' ?hw+�r 5/15)147 <br /> Signature of Applicant-Title Date <br /> E:NUS- KIMASTER.PSIENCROACHMENT PERMIT APPUCATION.DOC (01/08) <br /> Return Permits to: <br /> CCD <br /> P.O. Box 930 <br /> Stockton, CA 95201-0930 <br />