Laserfiche WebLink
APPLICATION FOR ENCROACHMENT PERMIT <br /> PLEASE PRINT• <br /> DateOFFICE USE ONLY <br /> To: San Joaquin County JOB # 67 REF # <br /> Department of Public Works APN CR # <br /> 'r-�7/' ;� EXP. DATE _ f S-b <br /> (-� VALID g5z407 TO 4,-15-67 DRIVEWAYS: <br /> (Applicant Name) STREET TPrx.14 LAME <br /> Al2EA STocK'ro,:�. QUAD SS <br /> �J TYPE-SE U_ 1-40i&-4 Tn2E MC-{4 <br /> (Mailing Address) FORMS _Ss/ww; P_-2'J <br /> . '/-f�� C 5 Z_C0z- NOTE <br /> (City, State, Zip Code) <br /> 6LCnD CmFZ_ 4-zl <br /> (Area Code - Telephone Number) <br /> Sketch (Detailed plans may be submitted) <br /> TRAFFIC CONTROL PLAN <br /> SHALL BE AS PER <br /> CURRENT M.U.T.C.D. <br /> CALIFORNIA SUPPLEMENT <br /> AE315 t <br /> I�o io2Z55o�g �' rz!k Z4, - <br /> The undersigned hereby applies for permission to .excavate, construct and/or <br /> othqrwis,e-encroach on County Highway Right-of-Way on-the ffAi5r si de.of <br /> approximate1 1216 � feet og <br /> of C ew D Cil . by --performing the <br /> fo�,lowing work '(descri tion of: wo ) : <br /> /791 work will commence on or about for approximately <br /> �bdays. <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 /> ins p n and ap roval. <br /> Signature of Appicant - Title <br /> Date <br /> C (� y�,t� ] <br /> Q <br /> MASTHR.PS\FnS®L (6100) l.•J •� J# `J� �Ool, - <br /> 03Afi� � <br />