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APPLICATION FOR ENCROACHMENT PERMIT <br /> PLEASE PRINT: <br /> Date � OFFICE USE ONLY <br /> To: San Joaquin County JOB# . -730052- REF# <br /> Department of Public Works APN CR# <br /> EXP.DATE -(S- K <br /> VALID Sl-( - (S TO 7-1 -6 DRIVEWAYS: <br /> Poci f is Gas cat Electric STREET r-atC e <br /> QUAD <br /> P.O. BOX 930 AREA j� - <br /> TYPE <br /> STOCKTON, CA 95201 FORMS Ss hi�zy <br /> 209-942-1627 NOTES <br /> Sketch(Detailed plans may be submitted) <br /> Traffic Control Plan <br /> shall be as per <br /> Sec; attached sketch. current M.U.T.C.D. <br /> California supplement <br /> PM -�51 !3 I Zoo <br /> Notif. <br /> The undersi ned hereby applies for permission to excavate, construct and/o-otherwise encroach on County Highway Right-of-Way on <br /> the side of 41CAI6 approximately IL6,' feet/mile <br /> ofMaf 6f. by performing the following work(description of work): <br /> Uz k1ory- Conno �2ZU5. <br /> T <br /> Work will commence on or about —for approximately 9 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 . KIMASTER.PSIENCROACHMENT PERMIT APPLICATION.DOC (01108) <br /> Return Permits to: <br /> CCD <br /> P.O. Box 930 <br /> Stockton, CA 95201-0930 <br />