Laserfiche WebLink
APP:L•ICATION FOR ENCROACHMENT PERMIT <br /> PLEASE PRINT: <br /> Date OFFICE USE ONLY <br /> To: San Joaquin County JOB # 75051-4, REF # <br /> Department of Public Works APN CR' # <br /> EXP. DATE 3 <br /> VALID TO G DRIVEWAYS: <br /> (Applicant Name) STREET lE,6GEy Abd <br /> AREA SSrk-A/ QUAD _ <br /> TYPE wF3E��?�t.1LE t f�G/QF <br /> (Mailing Add:_ess) FORMS <br /> (Cityn , NOTE <br /> , State, Zip Code) <br /> � �AtZ ICS's' <br /> Ar Code - Telephone Number) <br /> � � 3 <br /> 0 <br /> etcl f (entailed plans rr.ay be submitted) TRAFFIC CONTROL PLAN <br /> ar <br /> - SHALL BE AS PER <br /> c CURRENT M.U.T.C.D. <br /> CALIFORNIA SUPPLEMENT <br /> v <br /> i ,o : Ip2(o 2 <br /> The undersigned hereby applies for permission to excavate, cons ruct and/or <br /> otherwis encroach on County Highway Right-of-Way on the side of <br /> ��. approximately v7� feet/n-4 e <br /> of by performing the <br /> following work (description of work) : <br /> 6�1UIGe p �[ <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 /> Si ature of Applicant - Title Date <br /> RETURN <br /> t1FST _ 1,FEESCi-u7L (e/GU) PEF*XM TO: <br /> �p <br /> ..�/o PROMSSMi6 DESK BW I <br /> 4040 V%W L <br /> STOCKTCN, cA 9sw4 <br />