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APPLICATION FOR ENCROACHMENT PERMIT <br /> PLEASE PRINT: <br /> Date �I-I I ( OFFICE USE ONLY <br /> To: San Joaquin.County JOB# 730 5'Z REF# <br /> Department of Public Works APNCR# <br /> EXP. DATE f - - <br /> VALID -ZZTO (Z- DRIVEWAYS: <br /> Pac if is Gas & Electric STREET ttip <br /> P.O. BOX 930 AREA 5 Fa(s�py� QUAD <br /> TYPE 190(Igo le <br /> STOCKTON, CA 95201 FORMS �Z`t <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 '5(oq 1�I <br /> Notif. <br /> The undersi ned hereby appligS ffor perrmission to excgvate,construct and/or otherwise encroach on County Highway Right-of-Way on <br /> the � side of I� • l-fi�FA 1:5-r approximately feet/nQ6-- <br /> of W A S by pe orminngg the following work(description of work): <br /> Am h <br /> Work will commence on or about 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 /> QAn \0k a� <br /> E:1P(1Signature of Applicant-Title Date <br /> 1MASTER-PlIENC11.11MUff PERMIT APPLICATION.DOC (01108) <br /> Return Permits to: <br /> CCD <br /> P.O. Box 930 <br /> Stockton, CA 95201-0930 <br />