Laserfiche WebLink
APPLICATION FOR ENCROACHMENT PERMIT <br /> PLEASE PRINT• <br /> Date �°' V OFFICE USE ONLY <br /> To: San Joaquin Country JOB # -7301 3 REF # <br /> Department of Public Works APN CR # <br /> EXP. DATE 4- 1`of <br /> A T4T- L ��� �Q15 '�`� E > VALID.�"1-�a 7 TO 4- DRIVEWAYS: <br /> (Applicant Name) STREFT <br /> )-30DUrl�l.( l� � � A �, A QUAD <br /> TYPE <br /> (Mailing Address) FORMS <br /> is y J' TAS <br /> Ch G 5;,IU/, NOTE <br /> CJG.� 1.0 <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, onstruct and/or <br /> oth rwise encroach on County Highway Right-of-Way on the /�O1_T) side of <br /> approximately 510 feet/fie CfST-i WPST <br /> of apq) ttoa),4rd —, by performing the <br /> following work (description of work) : Ti^EnEfl D` /4 GIRT> 40 '.4CC©SS AS (FAL? <br /> RS &p0D /0A R&lle-r 0 D 17)an EMO YFI 6P&4d 'y0 SQ ,FT .'f 55011 67- <br /> Lr�r�Rx QF�u�v�a 76 g-OVI,06 "©UE,,AFD r,9V-1,4 frle-s FDf S R'fF Doe <br /> ASE aQ�F6r 6� !r7(r 7� v � 5;2,9a9az fib Lr�P, u oscso�s <br /> Work will commence on or about :3 -7'07 for approximately <br /> D,¢Yl .4 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 /> 1-1-7 ,�•2'� w <br /> Signa ure o Applicant - Title Date <br /> MASTER.PS\FEES=L (6/00) <br />