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APPLICATION FOR ENCROACHMENT PERMIT <br /> PLEASE PRINT: I <br /> Date 100 1* OFFICE USE ONLY <br /> To: San Joaquin,County JOB# -7 3 00 5-2 REF# <br /> Department of Public Works APN CR# <br /> EXP.DATE S—Sf— 15 <br /> VALID TO DRIVEWAYS: <br /> Pacific Gas & Electric STREET <br /> P.O. BOX 930 AREA QUAD S <br /> E' <br /> TYPE <br /> STOCKTON, CA 95201 FORMS <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 AZZa 7AZ I <br /> Notif. <br /> The undersigned hereby applies for permission to excavate, construct and/or otherwise encroach on County Highway Right-of-Way on <br /> the 0,61-r side of 6A 4111 til15<�rt approximately 06` feet/mile Iia" <br /> of W t lin Icy by performing the following work(description of work): <br /> L - i <br /> .. Work will commence on or about for approximately `fid 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:W - KIMASTER.PSIENCROACHMEM PERMIT APPLICATION.DOC (01108) <br /> Return Permits to: <br /> CCD <br /> P.O. Box 930 <br /> Stockton, CA 95201-0930 <br />