Laserfiche WebLink
APPLICATION FOR ENCROACMMMT PERMIT <br /> PLFsASE PRINT: <br /> Date OFFICE-IISS ONLY - <br /> To: San Joaquin County JOB /30 7 REF # <br /> Department of Public Works APN ( # <br /> • Cfi��i�ORN1H �1�t A�`�t� S��V , ,�ATS o <br /> lLTO 1-1-OS DRIVEWAYS: <br /> (Applicant Name) STREET f/A,Q1&15 ,LDv <br /> 1550 •FR�.MOW SV \� AREA 15�rX / QUAD �3 <br /> TYPE cff, <br /> `r WailingppAddress) :FORMS ZedAP4 <br /> 29 <br /> Sk ozx_tC11 c` Q 3 NOTE <br /> (City, State, .Zip Code) <br /> '-lbw-831 <br /> (Area Code - Telephone Number). <br /> Sketch (Detailed plans may be submitted) <br /> [,,J J <br /> The undersigned hereby applies for permission to.excavate, construct and/or <br /> otherwise-encroach-on County Highway Right-of-Wayoa-the sid�:•of <br /> approximately feet/mile <br /> of "- ' ,. • by performing the <br /> followin work (descri tion of work) : . - <br /> OF k-(' PVC 11L- Ono <br /> • . <br /> ST <br /> Work will commence on or'about for approximately <br /> lo® 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 /> Signature of Appli ant - Title Data <br /> lWSl1CK.PS\8ffi®L (6/061 . <br />