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APPLICATION FOR ENCROACHMENT PERMIT <br /> PLEASE PRINT: <br /> Date 10 �j� OFFICE USE ONLY <br /> _ To: San Joaquin County JOB# 7 3O®5-,—> # <br /> Department of Public Works APN CR# <br /> EXP. DATE 5-1S-15' <br /> VALID 4"15-/S TO DRIVEWAYS: <br /> Pacific Gas & Electric STREET AVM)-fano 1)"' <br /> P.O. BOX 930 AREA 51nCtjon QUAD_ <br /> TYPE -J;�a(4 CA <br /> STOCKTON, CA 95201 FORMS 5 <br /> 209-942-1627 NOTES <br /> Sketch(Detailed plans may be submitted) <br /> Tiraffic Control Plan <br /> shall be as per <br /> See attached sketch. current M.U.T.C.b. <br /> PMoCalifornia supplement <br /> �J' � lS3��- <br /> Notif. <br /> The undersigned hereby applies or permission to excavate,construct andlor otherwise encroach on County Highway Right-of-Wayon <br /> the 156-} side of f�Q1�o approximately feet/mde� <br /> Of 64K-V I&AD L/1 • _�, by performing the following work(description of work): <br /> rI PLO . <br /> Work will commence on or about 0 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 /> l�- <br /> Signature of Applicant-Title Date <br /> E:" . RMASTERRMENCROACHMENT PERMIT APPLICATION.DOC (01108) <br /> Return Permits to: <br /> CCD <br /> P.O. Box 930 <br /> Stockton, CA 95201-0930 <br />