Laserfiche WebLink
APPLICATION FOR ENCROACHMENT PERMIT <br /> PLEASE PRINT <br /> Date V ^b OFFICE USE ONLY <br /> To: San Joaquin County JOB # 73052-CA REF # <br /> Department of Public Works APN CR• # <br /> EXP. DATE S�d7 <br /> PC C® VALID. D7 TO -/5'0 DRIVEWAYS: <br /> (Applicant Name) STREET lAICL.19JJ2 AbL: <br /> AREA '5:F� Q QUAD <br /> 4c> SIV eST TYPE " %f eZ,101E <br /> (Mailing Address) FORMSS dls�l1T <br /> NOTE <br /> (City,/ State, Zip Code) <br /> '7- - 'A142 - �r-✓` -7 <br /> (Area Code - Telephone Number) <br /> Sketch (Detailed plans may be submitted) <br /> TRAFFIC CONTROL PLAN <br /> RETURNpEFW�'TO: SHALL BE AS PER <br /> MW CURRENT M.U.T.C.D. <br /> joe PFI0CES8ff4G DESK- BLD I CALIFORNIA SUPPLEMENT <br /> 4010 Wast Lens <br /> STOCKTON, CA 95204 <br /> �M 308 Z t 1 <br /> The undersigned hereby applies for permission to .excavate, construct and/or <br /> otherwise encroach on County Highway Right-of-Way on-the side_of <br /> Gj - SI',►GLa C _ approximately fee ./mile <br /> of �{�tz d(j�- ��'C�C `j by"performing the <br /> following work (description of, work) : 1,,15 11 . wa i - /Z« 1±Jm_ <br /> _��,�!1 cc �O �•�al c. �-'b Ca S 5�(J G l.,!>t� ���iJ t1 C-. STb�1_ <br /> Work will commence on or about \tom TD L p2nL 14J CU 0S i 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 /> -Gds �A t)e b - -7 -o <br /> Si at re of Applicant - Title S£ :01 WV 0 i ����; j��j Date <br /> MASTSR.WFERS®L (6100) _ 99 <br /> I <br /> I <br />