Laserfiche WebLink
APPLICATION FOR ENCROACHMENT PERMIT <br /> PLEASE PRINT:' <br /> Date OFFICE USE ONLY <br /> TO: San Joaquin County JOB # REF # <br /> Department of Public Works APN CR # <br /> EXP. DATE <br /> VALID• TO /S-US DRIVEWAYS <br /> (Applicant Name) STREET <br /> AREA _-TrGc,67GAI QUAD 5S <br /> L-�D V tel'✓ ' ��+ ''-� TYPE LG�`IoGE TiQE NGS+' <br /> (Mailing Address) FORMS <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 /> �CCURRENT M.U.T.C.D. <br /> 1� CALIFORNIASUPPLEMENT <br /> The undersigned hereby applies for permission to.excavate,',,construct and/or <br /> otherwise-encroach"on County Highway. Right-of-Wa:y-on the side.:of <br /> approximately _ feet/m*&e hLr)r- -in <br /> of LDurY,jet? , by -performing the <br /> following w rk (description of: work) : <br /> � 1.D�,u.? l• � .. ;, <br /> Work will commence on or about for approximately <br /> O 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 /> SitMPRESCEIDL <br /> ature of Applicant - Title :' C - ��l D t® <br /> . MAS (6/00) <br /> z <br /> i <br />