Laserfiche WebLink
APPLICATION FOR ENCROACHMENT PERMIT <br /> PL.:,,EASE PRINT: <br /> ` Q OFFICE USE ONLY <br /> Date _• ` <br /> TO: San Joaquin County JOB REF # <br /> Department of Public works APN CR # <br /> t <br /> EXP. DATE <br /> VALID -9-t9­1'0 TO f/f9e DRIVEWAYS <br /> (Applicant Name) STREET <br /> _ , A AREA ./vJ H IVT E/)QUAD - --- <br /> c� TYPE Ler ilG <br /> r <br /> (Mailing Address) FORMS <br /> NOTE <br /> � (C�ty,�t te, Zip Coda) <br /> (Area Code - Telephone Number) <br /> Sketch (Detailed plans may be submitted) TRAFFIC CONTROL PLAN <br /> SHALL BE AS PER <br /> CURRENT M.U.T.C.D. <br /> V CALIFORNIA SUPPLEMENT <br /> I�o �LDZ <br /> The undersigned hereby applies for permission to .excavate, construct and/or <br /> )n County Highway Right-of-Way on-the side of - <br /> otherwise encroacY} c t ' �� <br /> At I LA�, approximately hOCJ — feet/mile <br /> by "performing the <br /> of ' <br /> fo (description'ng work (description of work) : <br /> L� �:/4"1� � VIC� �2 GF�(�L-l'r4D1�.� GSE LUa —r— <br /> sQ <br /> Work will commence on or about for approximately <br /> R',L) 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 /> ins on and approval. <br /> 1 -a— �+ Date <br /> Signature of Applicant - Title :�� I 4 <br /> MASTRR.PS\FRES®L (6/00) <br />