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APPLICATION FOR ENCROACHMENT PERMIT <br /> PLEASE PRINT: <br /> Date 61 ! U 1 �, OFFICE USE ONLY <br /> To: San Joaquin County JOB# ) .�2 REF# <br /> Department of Public Works APN CR# <br /> EXP. DATE 10 - 1 - t4 <br /> VALID : 14- j¢TO _L0• [,- DRIVEWAYS: <br /> Pacific Gas & Electric STREET C <br /> P.O. BOX 930 AREA 1-horn-f QUAD / <br /> TYPE <br /> STOCKTON, CA 95201 FORMS 5 5ZWklper <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 --5t0-77qc4 <br /> Notif. <br /> The undersigned hereby applies for permission to excavate, construct and/or otherwise encroach on County Highway Right-±-.6u <br /> o-_ ,W,ayAon <br /> the side of M<lJ G�YSYI approximately_ A GLS feet/r <br /> of�-tern4Dni pa- _, by performing the following work(description of work): <br /> '.full . <br /> Work will commence on or about !v 3 —_for approximately 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 /> 0 of t�-- <br /> -Signature of Applicant-Title Date <br /> E:IPUB MMASTER.PSIENCROACHMEM PERMIT APPLICATION.DOC (01/08 <br /> Return Permits to: <br /> CCD <br /> P.O. Box 930 <br /> Stockton, CA 95201-0930 <br />