Laserfiche WebLink
APPLICATION FOR ENCROACHMENT PERMIT <br /> PLEASE PRINT• ` <br /> Date C ` OFFICE USE ONLY <br /> To: San Joaquin County JOB # //00,5' REF # — <br /> Department of Public Works APN CR' # - <br /> -� EXP. DATE _ O 7 <br /> C)(2.4j 0,, 2 cc VALID _ TO5/62DRIVEWAY3: <br /> (Applicant Name) ' STREET A <ZT <br /> AREA LDa/ QUAD //A/ <br /> TYPE ZL( EoL <br /> (Mailing Address) FORMS « u�wi X2-29 <br /> NOTE <br /> (City, State,, Zip Code) <br /> (Area Code Telephone Number) <br /> Sketch (Detailed plans may be submitted) <br /> The undersigned hereby applies for permission to excavate, construct and/or <br /> otherwise encroach on County Highway Right-of-Way on the , side of <br /> approximately 'v eet///)mile WC7T <br /> of kL'iyw 1' OOH`��4�ilGQ- �y performing the <br /> following work (description of work) : n5la\� ntie� av lv`i �V� Q Vi c� c ct <br /> Work will commence on or about ' 7 for approximately <br /> }`C.' 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 /> Signature of Applicant i Title Date <br /> MASTER.PS\FEESCHI)L (6/00) <br />