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APPLICATION FOR ENCROACHMENT PERMIT <br /> PLEASE PRINT: P5 - , 14_ 11 � <br /> p J <br /> Date 443-' t' l OFFICE USE ONLY <br /> To: San Joaquin County JOB# j Q REF# <br /> Department of Public Works APN CR# <br /> EXP.DATE t ''7 <br /> VALID �f-}-( TO CCI-3 i�-( ¢ DRIVEWAYS: <br /> Pacific Gas & Electric STREET AC10011 <br /> P.O. BOX 930 AREA QUAD _ <br /> TYPE <br /> STOCKTON, CA 95201 FORMS �-�ZV141 Ae> <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 <br /> Notif. <br /> The undersigned hereby applies for permission to excavate, construct and/or otherwise encroach on County Highway Right-of-Way on <br /> 01 <br /> the side of approximately #e2t/xz <br /> of , by oerforming the following work(description oT work): <br /> Work will commence on or about for approximately q9 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 hM2 eq <br /> Signature of Applicant-Title 'Datb <br /> ", KIMASTER.PSIENCROACHMENTPERMITAPPLICATION.DOC (01108) <br /> Return Permits to: <br /> CCD <br /> P.O. Box 930 <br /> Stockton, CA 95201-0930 <br />