Laserfiche WebLink
APPLICATION FOR ENCROACHMENT PERMIT <br /> PLEASE PRINT: <br /> o c '-7 OFFICE USE ONLY <br /> Date �� �� � 2 <br /> JOB #—I IOC�S' REF # <br /> # <br /> To: San Joaquin County APN CR <br /> Department of Public Works EXP DATE c;,07 <br /> VALID <br /> �- t S-�-7 TO DRIVEWAYS <br /> ' S y✓�,tl STREET <br /> (APP icant Name) <br /> + <br /> AREA ScAC QUAD - -- <br /> TYPE <br /> yr FORMS <br /> - <br /> (Mailing Address) NOTE <br /> (City, State) Zip Code) <br /> qy�s�=-7 <br /> (Area Code - Telephone Number) <br /> Y <br /> Sketch (Detailed plans may <br /> be submitted) <br /> -?Y L <br /> applies for permission to excavate, construct and/or of <br /> The undersigned hereby pp Highway Right-of-Way on the <br /> i7 r7 si <br /> feel/mile <br /> otherwise encroach on County approximately by performing the <br /> o f S �' ` G <br /> follow(�ng work (description of wor ) : -�( , L <br /> �2 'C� ��� for a proximately <br /> Work will commence on or about <br /> day,4' <br /> ective property, or am <br /> I the undersigned certify that I am threewtrfep <br /> odotheworkdescribed above in <br /> er and <br /> qualified to represent the °`^mulationsgof San Joaquin County and subject to <br /> accordance with the rules, reg <br /> inspection and approval. <br /> r- G <br /> t . ,r G Date y <br /> Ji5dnLaJtur of App <br /> licant - al.le CS T i,✓0 13 � e <br /> MASTER.PS\FEESCFDL (6/00) V <br /> C <br /> r <br />