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APPLICATION FOR ENCROACHMENT PERMIT <br /> PLEASE PRINT: J <br /> Date t 1 /5 l( 1 OFFICE USE ONLY <br /> To: San Joaquin County JOB# -(o REF# <br /> Department of Public Works APN 4 CR# <br /> EXP.DATE /� L <br /> VALID /is <br /> /Z 0. Is'l2 DRIVEWAYS: <br /> Pacific Gas & ElectricSTREET <br /> P.O. BOX 930 1 AREA _-570-eAWAI QUAD WS <br /> TYPE �QCE <br /> STOCKTON, CA 95201 FORMS 5 AIIM LS <br /> 209-942-1627 I NOTES <br /> I <br /> Sketch(Detailed plans maybe submitted) <br /> Traffic Control Plan <br /> shall be as per <br /> See attached sketch. current M.U.T.C.D. <br /> California supplement j <br /> Notif. l o55cq��l <br /> The undersigned hereby applies for pemission to excavate,construct and/or otherwise encroach on County Highway Righ-of-Way on <br /> the 4 side of approximately Z. feet/rr:i <br /> of , , by performing the following work(description of work): <br /> v <br /> Work will commence on or about 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 /> work described above in accordance with the rules and regulations of San Joaquin County and subject to inspection and approval. <br /> \ awu • . 6/0 <br /> Signature of Applicant-Title Dat <br /> E . KMSERPS1ENCROACHMENT PERMIT APPLICATION.DOC(01108) <br /> Return Permits to: <br /> CCD <br /> P.O. Box 930 <br /> Stockton, CA 95201-0930 <br />