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APPLICATION FOR ENCROACHMENT PERMIT <br /> PLEASE PRINT: <br /> Date �J��/ , g >� OFFICE USE ONLY <br /> __.=San-Joaq tY uin_Coun:: - -_- - -- .- - _ :JOB.# <br /> — - <br /> Department of Public Works APN CR# <br /> EXP.DATE <br /> PaC1fIC ��� �.IIOj �lectrlc ®. VALID 5T0 <0,3j-��� DRIVEWAYS: <br /> STREET <br /> LM AREA ' ;QUAD <br /> Stockton, CA 95204- TYPE <br /> FORMS C <br /> - NOTES <br /> (Area Code e Telephone Number) <br /> Sketch(Detailed plans may be submitted) <br /> ' 1 <br /> Traffic Control Plan <br /> See attached sketch. Shall be as,per l <br /> PM (��t � f current M.U.T.C.D. <br /> Motif. '�6 �����-- California supplement. <br /> Please return permit to: <br /> CCD Desk <br /> 4040 West Lane <br /> Stockton, CA 95204 <br /> , l <br /> ��e unders�ned ereby applies for permission to excavate,construct and/or othervuise encroach_ on County Highway Right-of-W y on <br /> side of_ ,���� approximately �1 [� feet/�Z_- __ <br /> of � LC9D I . ,6y performing the following work(description of work): <br /> iN cv:wil(commence on or about for approximately da s.. <br /> y <br /> 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 /> vork des ' ed above in accordance with the rules and regulations of San Joaquin County and subject to inspection and approval., <br /> R <br /> Signafiure of Applican -Title ale <br /> °UB-SV.WKIMASTER.PS(ENCROACHMENr PERMITAPPLICATION.DOC(01108) <br /> Please return permit to: <br /> CCD Desk <br /> 4040 West Lane <br /> Stockton, CA 95204 <br />