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APPLICATION FOR ENCROACHMENT PERMIT <br /> PLEASE PRINT: <br /> Date J Z�f `A, OFFICE USE ONLY <br /> To: San Joaquin:County JOB# REF# <br /> Department of Public Works APN CR# <br /> EXP.DATE <br /> VALID TO DRIVEWAYS: <br /> Pacific Gas & Electric STREET t-10 ba 1 cf A I/ <br /> P.O. BOX 930 AREA S hoc k-- tip► QUAD <br /> TYPE <br /> STOCKTON, CA 95201 FORMS 4� 4Z141 R 2_ci <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 /> PM `5 Ion 15-!-57 California supplement <br /> Notif. <br /> The undersigpe_d hereby applies for permission to excavate, construct and/or otherwise encroach on County Highway Right-of-Way n <br /> the c� side of )-vapproximately feet/wft <br /> of A tea/ ` �- by performing the following work MC. �(description of work): <br /> 550 3 Polba ' i . <br /> Work will commence on or about o 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 /> Qaq \&Dft�j . <br /> Signature of Applicant-Title Date <br /> E:N KIMASTERPSIENCROACHMENT PERMIT APPLICATION.000(01/08) <br /> Return Permits to: <br /> CCD <br /> P.O. Box 930 <br /> Stockton, CA 95201-0930 <br />