Laserfiche WebLink
APPLICATION FOR ENCROACHMENT PERMIT <br /> PLEASE PRINT: <br /> Date OFFICE USE ONLY <br /> To: San Joaquin County JOB# 6O&,S REF# <br /> Department of Public Works APN CR# <br /> EXP.DATE /- /S' 7Ci12- <br /> r4e S.>w e, Grou/o, _Ync. VALID I-l-2gAZ_ TO [-/5-2012 DRIVEWAYS: <br /> (Applicant Name) STREET jZd\. <br /> AREAS loG�FE QUAD _ <br /> 9Yy cCoe✓4+e /I�( Sa rl TYPE '3 " <br /> ( ailing Address) FORMS S�f�� tJ <br /> / NOTES <br /> C�r�ss (kA/ 9S9Y <br /> City,State, Zip Code) <br /> lS3o)z71-Ywc� <br /> (Area Code-Telephone Number) <br /> Sketch(Detailed plans may be submitted) <br /> The undersigned hereby applies for permission to excavate,construct and/or otherwise encroach on County Highway Right-of-Way on <br /> the sow-fA side of approximately /.2 feet/miles c er/ <br /> of Se..-IA Toek 4&z �i by performing the following work(description of work): <br /> '5-e= ,// it - rf// - •fleet N+en/Af�iMa r.�ods c%.. 0� .A,d"i ><=I r e. 6,1114 <br /> �z d -a e A� f /I 1 <br /> 1 L co tso/r•frd us' � -ir^a 4 /ro � ra �a rel (..eN 6or, 4- 4.a!/ <br /> Work will commence on or about for approximately 5 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 /> Signature of Applicant-Title Date <br /> EVU1 .WH4 MKPMNCRORCHMEMPE WM UCAT N.MOC 010) <br />