Laserfiche WebLink
APPLICATION FOR ENCROACHMENT PERMIT <br /> PLEASE PRINT: <br /> Date �t C> -cz OFFICE USE ONLY <br /> TO: San Joaquin County JOB # REF # <br /> Department of Public Works APNCR # <br /> EXP. DATE /r 07 <br /> C CLQ ' VALID -�' TO 7' -D7 DRIVEWAYS: <br /> (Applicant Name) STREET �r <br /> AREAAl QUAD <br /> TYPE ZELL LF <br /> (Mailing Address) FORMS _ Z <br /> NOTE <br /> (city, state, Zip Code) <br /> (Area Code - Telephone Number) <br /> Sketch (Detailed plans may be submitted) TRAFFIC CONTROL PLAN <br /> SHALL BE AS PER <br /> 1 Cn CURRENT M.U.T.C.b. <br /> CALIFORNIA SUPPLEMENT <br /> The undersigned hereby applies for permission to .excavate, construct and/or <br /> otherwise-encroach on County Highway Right-of-Way-on.-the G 1 side.of - <br /> A�� approximately g- 1 �� wee /mile �c�u TA <br /> of /�i 4-4 Y bi� , S-Ce c��. by=per€ormirig the <br /> following work (description of, work) : yz' <br /> j-IL2 t <br /> X 51L <br /> Work will commence on or about JUL-:-1 ` c J for approximately <br /> 2 days. <br /> I, the undersigned certify that I am the owner of the re spective, 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.. JJ <br /> At <br /> Si nature of Applicant - Tit16 ' : � QZ Date <br /> MASTER.PS\FRES®L (6/00) <br /> 0.3t�tt� �r <br /> i <br />