Laserfiche WebLink
APPLICATION FOR ENCROACHMENT PERMIT <br /> PLEASE PRINT: <br /> Date OFFICE USE ONLY <br /> REF # <br /> To: San Joaquin County <br /> Department of Public Works APN CR # <br /> EXP. DATE <br /> VALID 7 Olp TO 2 SD DRIVEWAYS: <br /> "`��"'��� �LY��'i�� /G!/• <br /> (Applicant Name) STREET <br /> AREA CQUAD –M5 <br /> tU'A, — <br /> TYPE <br /> (Mailing Address) w,, FORMS 119)WI e Z <br /> � <br /> h NOTE.. <br /> (City, State, Zip Code) <br /> (Area Code - Telephone Number) <br /> Sketch (Detailed plans may be submitted) TRAFFIC CONTROL PLAN <br /> SHALL BE AS PER <br /> CURRENT M.U.T.C.D. <br /> i, CALIFORNIA SUPPLEMENT <br /> pM: X05 1.U� <br /> o lo2v 2�'15o::; <br /> The undersigned hereby applies for permission to excavate, st�u t and/or <br /> other ' se e croach o County Highway Right-of-Wa on the <br /> s/ s' e of <br /> Do ihapproximately feet/ni'f'ty <br /> of by p rforming the <br /> VAA <br /> folio in 'work (d sc ti �`of w rk) :1�� <br /> L t- <br /> Work will commence. on or about for approximately <br /> _ days. <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 /> (\ I �q. I- 14 a 2 i � <br /> + .t:::) <br /> ff <br /> Si <br /> al of Applicant - Title Date <br /> RETURN PERmrm TO: <br /> MAST -P \FEEMML (6/00) • M <br /> J09,PROCE SSM DESK BLD 1 <br /> 4W W09 Lana \ <br /> 81 VCKTON, CA 95204 <br />