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APPLICATION FOR ENCROACHMENT PERMIT <br /> PLEASE PRINT: <br /> Date 4/1-7,115 OFFICE USE ONLY <br /> To: San Joaquin County JOB# REF# <br /> Department of Public Works APN CR# <br /> EXP. DATE <br /> VALID TO g-1-[S DRIVEWAYS: <br /> Pacific Gas & Electric STREET ,IaP0 <br /> P.O. BOX 930 AREA ��on4 QUAD S E <br /> TYPE llk)le <br /> STOCKTON, CA 95201 FORMS 55I''W Riq <br /> 209-942-1627 NOTES <br /> Sketch(Detailed plans may be submitted) <br /> Traff is Control Plan <br /> shall be as per <br /> See attached sketch. current M.U.T.C.D. <br /> PM 42---"�oq78 California supplement <br /> Notif. <br /> The undersigned hereby applies for permission to excavate, construct and/or otherwise encroach on County Highway Right�-off-W_a�y on <br /> the h side of ML�l � approximately ' feeYA&�L <br /> of R� byperforming the following work(description of work): <br /> 40 <br /> ' x�►' ave. as �e'�'U6� ��� rI�317 �•N<<LiGo <br /> Work will commence on or about _for approximately 90 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 /> Y <br /> QLm 411 1 1 <br /> E:1PLSignature of Applicant-Title Date <br /> WASTER PSIENCROACHMENT PERMIT APPLICATION.DOC (01/08) <br /> Return Permits to: <br /> CCD <br /> P.O. Box 930 <br /> Stockton, CA 95201-0930 <br />