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APPLICATION FOR ENCROACHMENT PERMIT <br /> PLEASE PRINT: <br /> Date f - OFFICE USE ONLY <br /> To: San Joaquin County JOB# 7 3 aREF# <br /> Department of Public Works APN CR# <br /> EXP.DATE S (- <br /> VALID TO -3 - DRIVEWAYS: <br /> Pacific Gas & Electric STREET OU Sf x <br /> P.O. BOX 930 AREA 4foc L40rl QUAD S� <br /> TYPE <br /> STOCKTON, CA 95201 FORMS SS/ / WZ XZ 2-97 <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 /> PM <br /> Notif. <br /> The undersigned hereby applies for permission to excavate,construct and/or otherwise encroach on County Highway Righ� <br /> th side of approximately 180 feeWaile <br /> of V. 61 , by performing the following work(description of work): <br /> o -tt!'V tCa' �-� <br /> Work will commence on or about for approximately n 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 /> \03D UWU , /Jr 6a/b ;PA+�r <br /> Signature of Applicant-Title bate <br /> E:IP MMASTER.PSIENCROACHMENTPERMITAPPLICATION.DOC (01108) - <br /> Return Permits to: <br /> CCD <br /> P.O. Box 930 <br /> Stockton, CA 95201-0930 <br />