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APPLICATION FOR ENCROACHMENT PERMIT <br /> PLEASE PR T: I /� <br /> Da a I U OFFICE USE ONLY <br /> icB # �J?= (" cEr <br /> T-) : San Jcaqu�: County <br /> artment of Public Works a--2-N — `-F <br /> �� <br /> EXP. DATE <br /> VL <br /> VALID 1 a 0 TO t _— DRIVEWAYS: <br /> (A 1.1c t Name) STREET <br /> P.REA �1=W QUAD <br /> TYPES/�GL6 80i� m <br /> (Mailing Address) FORMS ff=.1111AQ. -+ �t <br /> �����i���►`�lJ� � ���� NOTE <br /> r9 t <br /> (Cit s te, Zip Code) _ <br /> (cl� 7 <br /> a Code - Telephone Number) C. <br /> ---�--'— <br /> 30 Ul <br /> rwN <br /> Sketch (Detailed plans may be submitted) <br /> no A <br /> � � Z <br /> o rn o <br /> „ CO >.m <br /> C <br /> c3 <br /> �r <br /> �,Wil' <br /> N 4 <br /> 0 0 <br /> av 4 <br /> The undersigned hereby applies for permission to excavate, con true and/or <br /> of r.Wi e encroach o County Highway Right-of-Way on the s e of <br /> approximatel feet/ _ <br /> ofellby p rf renin th <br /> following work (descriptio of work): <br /> Work will commence on or about for aapro:cimat=ly <br /> -- days <br /> I the undersigned certify that I am the owner of r_he respect,-ve property, or am <br /> qualified to represent the owner and agree to do t:.e work described above in <br /> accordance with the rules, regulations of San Joaquin County and 5,atject to <br /> inspection and approval. <br /> .qty. <br /> RETURN PERMITS TO: <br /> iMx S^£Z PS'^e££S�7HDL (6/401 <br /> PG&E <br /> JOB PROCESSING DESK -BLD 1 <br /> 4040 WEST LANE <br /> cTnruTnN f:A 95204 <br />