Laserfiche WebLink
APPLICATION FOR ENCROACHMENT PERMIT <br /> PLEASE PRINT• <br /> Date /C;i OFFICE USE ONLY <br /> To: San Joauin County JOB # "�✓ REF # <br /> Departme of Public. Works APN CR' # Z�,7_3— <br /> �� } EXP. DATE <br /> VALID 9//2701 TO - DRIVEWAYS: <br /> ( pplic t. Name) STREET y <br /> //!��/ 1 AREA Sy$ VVA) QUAD <br /> `C [ �t'� r_ f o� TYPE X/X-4* 62/l•� <br /> (Mai ing Address) FORMS S Lana NOTE <br /> (City, State, Zip Code) <br /> (Area Code - Telephone Number) <br /> Sketch (Detailed plans may be sub itted) <br /> The undersigned hereby applies for permission to excavate, construct and/or <br /> otherwise encroach on County Highway Right-of-Way on tie 5*f- side of <br /> QV r412— 13 `j'r approximately �P�� feet/mile <br /> of by performiW the <br /> following work (description of work) J' ( y ��2- �A_0 L", <br /> 14, <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 /> inspZcon and approval. <br /> 1-7 <br /> Signature of Ap is t - i Da e <br /> MASTER.PS\FEESCHDL (6/00) <br />