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APPLICATION FOR ENCROACHMENT PERMIT <br />PLEASE PRINT: <br />Date of <br />OFFICE <br />JOB# ? '3 <br />APN <br />EXRDATE 2-("� <br />VALID 12 18. 17 <br />STREET / r 0-- <br />USE ONLY <br />REF # <br />CR # <br />f <br />TO 7 - 1- (8 DRIVEWAYS: <br />To: San Joaquin County <br />Department of Public Works <br />PG&E <br />(Applicant Name) <br />4040 West Lane <br />AREA <br />TYPE <br />FORMS <br />NOTES <br />QUAD <br />(Mailing Address) <br />Stockton, CA. 95204 <br />(City, State, Zip Code) <br />(209) 409-2083 <br />(Area Code - Telephone Number) <br />WAT8(c-)PGE.00M <br />(Email Address) <br />Sketch (Detailed plans may be submitted) <br />SEE ATTACHED <br />DRAWING <br />PM # <br />�f3oyy��� <br />The undersi ned hereby applies for permission to excavate, construct and/or otherwise encroach on County Highwa Right -of -Way on <br />the side of CAerp/Lee Aid. approximately 4 ' et e mile Lt/ <br />of M Fi ! heti- Li- , (S C'4AM , by performing the following work (description of work): <br />Ccf�_ /W' AeJfDca-aorO <br />Work will commence on or after /I forapproximately OP- 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 />11'�A�1- xn�- <br />Signatur ofApplic -Title Date <br />YTORMS B TEMPLA1 VENCROACHMEM PWAIT APPUWON.doc(008) <br />