Laserfiche WebLink
APPLICATION FOR ENCROACHMENT PERMIT <br /> PLEASE PRINT: <br /> OFFICE USE ONLY <br /> To: San Joaquin County JOB # 7305 Z- Lp REF # <br /> Department of Public Works APN CR # <br /> EXP. DATE <br /> T VALID• i a-� TO 2-l S-vA DRIVEWAYS <br /> (Applicant Name) STREET o c- H El . <br /> ` <br /> �t-� q AREA MRNiE�w1 QUAD/0 L/� W e.j4- L K—{ TYPE t, Hots 2 2EJUCk <br /> (Mailing Address) FORMS 4X <br /> L <br /> NOTE <br /> (City, State, Zip Code) <br /> Z®q - qy2 - I76, o <br /> (Area Code - Telephone Number) <br /> Sketch (Detailed plans may be submitted) TRAFFIC:CONTROL PLAN <br /> SHALL BE APER <br /> CURRENT M:U_T.C.D. <br /> CALIFORNIA'SUPPLEMENT <br /> RETUM PERMITS TO: <br /> PGM <br /> MSK EMM +)r743 1�5_( <br /> JOB PFK)MS3*4G4W West LN" <br /> S1 )KION- CA95204 <br /> The undersigned hereby .applies for permission to .excavate, construct and/or <br /> otherwise-encroach on County Highway Right-of-Way on-the oLk4k side_of - <br /> .9-b it ee e V h ,� /� approximately l 34 �D' mile L J e5-E' <br /> ofa0r i v� 5 /� � ✓� by per€f rming the <br /> following work (description of work) : 13-e� `� L sit �YG� <br /> ►. �la.f �Y�"�1.S•P �y�� � Nor .� N�c,/ btsl 5 SrsB <br /> Work will commence on or about O /Z-76 7 for approximately <br /> ' <br /> t Z J 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 ;, a <br /> accordance with the rules, regulations of San Joaquin County and subject to y <br /> inspection and approval. <br /> 7-1 <br /> Signature of'J[pplf&&nt - Title Date <br /> MASTER.PS\FRES®L (6/00) O <br /> i <br />