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APPLICATION FOR ENCROACHMENT PERMIT <br /> PLEASE PRINT: I ,i <br /> Date `� 1 I OFFICE USE ONLY <br /> To: San Joaquin County JOB# 1-224713 0[) Z REF# <br /> Department of Public Works APN CR# <br /> EXP. DATE If - ( – ( S <br /> VALID TO ¢- - ( 5 DRIVEWAYS: <br /> Pac i f is Gas & Electric STREET n De(/ <br /> P.O. BOX 930 AREA W gxic,��PUAD � <br /> TYPE aellholle <br /> STOC KTON, CA 95201 FORMS Sr;��Y�„i 2,9 <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 :5Ill108 <br /> Notif. <br /> The undersigned hereby applies forppermission to excavate,construct and/or otherwise encroach on County Highway Right-of-Way on <br /> the tF- side of D*Cle-I approximately flG1 OO feeVeak <br /> of UOUIJ466 lkyp _ -c��.�bfl _, by performing the following work(description of work): <br /> Ye, 40 358 O'De I <br /> Work will commence on or about —for approximately �o 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 /> Signature of Applicant-Title Date <br /> E:1P MMASTER.PSIENGROACHMENT PERMIT APPLICATION.DOC (01/08) <br /> Return Permits to: <br /> CCD <br /> P.O. Box 930 <br /> Stockton, CA 95201-0930 <br />