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APPLICATION FOR ENCROACHMENT PERMIT <br /> PLEASE PRINT: <br /> Date 12 L,I i A- OFFICE USE ONLY <br /> To: San Joaquin County JOB# 730052— REF# <br /> Department of Public Works APN CR# <br /> EXP.DATE 4-1 .5- I S <br /> VALID —ZZ- TO g- S l S DRIVEWAYS: <br /> Pacific Gas & Electric STREAREA QUAD A/� <br /> P.O. BOX 930 <br /> TYPE <br /> STOCKTON, CA 95201 FORMS 5S U/ W Z�'Seal <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 /> PM3112a1�� <br /> Notif. <br /> The undersigned hereby applies for permission to excavate, construct and/or otherwise encroach on County Highway Right-of-Wayon <br /> the u side of O �approximately 114 feet/r> 9" <br /> of tpMGr by performing the followin work(description of work): <br /> 14 LNii <br /> A xfy- -0' <br /> Work will commence on or about for approximately ![o days. <br /> I If <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 /> 0 <br /> Signature of Applicant-Title Date <br /> E:IP NIMASTER.PMENCROACHMENT PERMIT APPLICATION.DOC (01108) <br /> Return Permits to: <br /> CCD <br /> P.O. Box 930 <br /> Stockton, CA 95201-0930 <br />