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APPLICATION FOR ENCROACHMENT PERMIT St <br /> PLEASE PRINT: <br /> Date M404AA S Zcol OFFICE USE ONLY <br /> To: San Joaquin County FAPN —i <br /> Z_� REF# <br /> Department of Public VVorks <br /> CR# <br /> EXP. DATE ---- . —� <br /> VALID 3•Z •O TO 69-bo DRIVEWAYS: <br /> P.G. &E. CO. STREET <br /> 4040 WEST LANE <br /> AREA -,�Al QUAD, <br /> STOCKTONTYPE <br /> , CA 95204 FORMS - <br /> amuMr- <br /> NOTES <br /> ' <br /> �(ANaCode�-Tele�phoneUumbe�r) � <br /> Sketch (Detailed plans may be submitted) <br /> See attached sketch. Traffic Control Plan <br /> PM -36( '�� Shall be as per <br /> current M.U.T.C.D. <br /> Notif. 1p3-7 t®Z,7L' California supplement. <br /> i <br /> The un ersigned hereby applies f r permission to pxcr\a�vate,construct and/or otherwise encroa h o Founty Highway Right-of-Way on <br /> the a side of d L- �� <br /> of approximately feet/mila <br /> o by performing the following work(description offwwoorrk <br /> AZ51-f1 <br /> Work will commence on or about <br /> for approximately <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 Jv <br /> work described above in accordance with the rules and regulations of San Joaquin County and subject to inspection and approval. <br /> �. <br /> DL.� <br /> Signat re of Applicant-Title <br /> Date <br /> E:WUB-SV.WKUNSTERPSIENCROACHMENT PERMIT APPLICATION.DOC X01108) <br />