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APPLICATION FOR ENCROACHMENT PERMIT <br /> PLEASE PRINT': ` <br /> Date :7 I'E�7 OFFICE USE ONLY <br /> -_ To:-----San-Joa uin_Coun -- - --_--- - - - - _ ::JOB-#_-: --._.. <br /> Department of Public Works APN CR# <br /> EXP.DATE to-(� -( <br /> Pacific Gas and Electric C®. VALID l-ls TO - s DRIVEWAYS: <br /> * <br /> ,�A +�e7— LM. AREA QUAD �f <br /> (( * <br /> �t®cStockton, �� ���� TYPE- FORMS S tt/fol zi <br /> NOTES <br /> (Area Code-Telephone Number) <br /> Sketch <br /> Detailed <br /> ( plans may be submitted) 1 <br /> Traffic Control Plan <br /> See attached sketch. Shall be as per <br /> PM i current M.U.T.C.D. j <br /> Notif. i 1644_-)b5l 7 i California supplement. <br /> Please return permit to: <br /> CCD Desk <br /> 4040 West Lane <br /> Stockton, CA 95204 <br /> i <br /> The undersigned hereby applies for permission to excavate,construct and/or otherwise encroach on County Highway Right-of-Way on <br /> the 56t4'M side of LI approximately feet/ � <br /> of 1;::(l..l3t'9FZ 5r ,by performing the following work(description of work): <br /> Work will commence on or about KQ 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 /> wor ed above in accordance with the rules and regulations of San Joaquin County and subject to inspection and approval., <br /> AC? I� <br /> Signature of Applicant-Title D .e <br /> EIPUBSV.WMMASTER.PS(EMCROACHMENTPERMITAPPLICATION.DDC(U110B) <br /> Please return permit to: <br /> CCD Desk <br /> 4040 West Lane <br /> Stockton,CA 95204 <br />