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APPLICATION FOR ENCROACHMENT PERMIT <br /> PLEASE PRINT: <br /> Date �I (� OFFICE USE ONLY <br /> To: San Joaquin County JOB# 7O n S Z REF# <br /> Department of Public Works APN CR# <br /> EXP. DATE - - <br /> VALID ^ -Zj- tS TO -t-(S DRIVEWAYS: <br /> Pacific Gas & Electric STREET <br /> P.O. BOX 930 AREA Ou D <br /> TYPE Ge- Ude <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 /> Pm--51 !*04 to Coal ifornia 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 side of approximately feet/rrrle, <br /> of _, by performing the following work(description of work): <br /> 1111 104 J2 �QJIMA2- <br /> Work will commence on or about g i S 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?P . MMASTER.PSIENCROACHMENT PERMIT APPLICATION DOC (01108) - <br /> Return Permits to: <br /> CCD <br /> P.O. Box 930 <br /> Stockton, CA 95201-0930 <br />