Laserfiche WebLink
F <br /> APPLICATION FOR ENCROACHMENT PERMIT <br /> PLEASE PRINT: <br /> Date �/ OFFICE USE ONLY <br /> To: San Joaquin County JOB # '730!5z-C4;' REF # <br /> Department of <br /> Public Works APN CR # <br /> C-;> . P�G�• <br /> EXP. DATE <br /> VALID 4/- =07. TO 6-15107 DRIVEWAYS: <br /> (Applicant Name) STREET _bL-DLFy ZD. <br /> AREA r'� c N CAM f QUAD <br /> � r �!�'� TYPE i I o LC_ TFzc�Ucy t <br /> (Mailing Address) FORMSL5 44y, i'- ;17 <br /> NOTE <br /> (C ty, State,, Zip Code) <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 /> RETUM PERMITS TO:PGM <br /> L / <br /> JOB PROCESSING DESK- BLD 9 <br /> BIW Vftm Lang <br /> STOCKfON, CA 9=4 <br /> The undersigned hereby applies for permission to.excavate, construct and/or <br /> otherwise encroach on County Highway Right-of-Way oa-the side.of <br /> approximately <br /> of ✓� ��f'ea ti by e-rformin til e <br /> following work (des ri tion of work) : �/ �r <br /> v�rJ !N �. "7 GX , 1.3-1- Y Gh' <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 /> SX) 7 <br /> Signature of Applicant - Title <br /> pp ate <br /> E.S :6 NV 0 Z 8VW LGOZ <br /> MASTER.MFEESCEDL (6/00) - <br /> f, 0 U <br />