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APPLICATION FOR ENCROACHMENT PERMIT <br /> PLEASE PRINT- <br /> Date r' o2L�Q <br /> OFFICE USE ONLY <br /> To: San Joaquin County .JGB # <br /> Depar-tment of Public Works REF # <br /> APN CR ## <br /> ���✓ �� / EXP. DATE ti p <br /> d� fCo( VALID 3 .21 0 TO . <br /> DRIVEWAYS. <br /> (Applicant Name) STREET AQ <br /> RETURN PERMITS TO: AREA ' '' QUAD - -- <br /> PG&E _ TYPE _-2916 QE ` <br /> � <br /> JOB PROCESSING DESK,BLD 1 NOTE FOTE <br /> 4040 West Lane _ <br /> Stockton, CA 95204 <br /> WCO <br /> (Area Code - Telephone Number) <br /> Sketch (Detailed pYans may besubmitted) <br /> Ir'f C� <br /> "U G= <br /> 0 r <br /> C3 <br /> The undersigned hereby applies for permission to excavate, costruct and/or <br /> othe ise encroa h on C,punty Highway Right-of-Way on the "�B, / <br /> y/ �ie/(/� % fGlside of <br /> approximately of ///Y lrl� y f �by 'performing <br /> ile _ .f. <br /> following work (description of work) the <br /> Workwill commence on or about <br /> ZO days: for approximately <br /> I, the undersigned certify that I am the owner of the respective property, or am <br /> qualified to represent the owner and agree to do the work described above in <br /> accordance with the rules, regulations of San Joaquin County and subject to <br /> inspection and approval. <br /> Si gnat - G ez nt, scant <br /> ye 1 Date <br /> MASTER.PS\FEESCIDL (6/00) ��( .~ ��� I <br />