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APPLICATION FOR ENCROACHMENT PERMIT <br /> PLEASE PRINT:: <br /> Date i oI Z4 f 1,4 OFFICE USE ONLY <br /> To: San Joaquin County JOB REF# <br /> Department of Public Works APN CR# <br /> EXP.DATE <br /> VALID 4--7-LFTO -7- - I5 DRIVEWAYS: <br /> Pacific Gas & Electric STREET ::�-f h <br /> AREA .51 QUAD _ <br /> P.O. BOX 930 <br /> TYPE C <br /> STOCKTON, CA 95201 FORMS 5SW <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 t)l 10California supplement <br /> Notif. <br /> The undersi ned hereby applies for permission to excavate,construct and/or otherwise encroach on County Highway Right-of-Way on <br /> the U side of L approximately-?.Z;-7 11a feet/ <br /> of Ahh by performing the following work(description of work): <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 /> Q�m \06D awu ' Iq /IAr <br /> E:4^(ISignature of Applicant-Title Date <br /> NASTERFSENCRQACHMENT PERMIT APPLICATION.DOC (01100) . <br /> Return Permits to: <br /> CCD <br /> P.O. Box 930 <br /> Stockton, CA 95201-0930 <br />