Laserfiche WebLink
APPLICATION FOR ENCROACHMENT PERMIT <br /> PLEASE PRINT: <br /> Date "� - /? -'�C a e OFFICE USE ONLY <br /> To: San Joaquin County JOB # 75eV< �._:S REF # <br /> Department of Public Works APN CR # <br /> EXP. DATE - <br /> i VALID TO /S C / DRIVEWAYS: <br /> (Applicant Name) STREET <br /> AREA Ox�IZQUAD- IVl1t) <br /> TYPE _ a/ Ck4 t ''' <br /> (Mailing Address) FORMS Gam. <br /> NOTE <br /> S TL C K T* ,'J C A S ! ? <br /> (City, State, Zip Code) <br /> R 01 - y 7�- y 75`1 — <br /> (Area Code - Telephone Number) <br /> Sketch (Detailed plans may be submitted) <br /> A-77A C M f.-.b <br /> The undersigned hereby applies for permission to excavate, construct and/or <br /> oth`jrwise encroach on County Highway Right-of-Way on the - 14f.S T side of <br /> 'V /4 a (1'�� 'S7 approximately ® feet/ i"w 400- "H <br /> of AUG V S TA AfiL. , byerforming the <br /> following work (description of work) : m' O C t.�*&Jr. W-1 UC I-A 0 1 AJ&r , M it -T- rp&J 6 q i r r* R*L4 A#J <br /> STN <br /> fib ' /- c4 T Tz> E k t S Toje-0, f,4-k w*-'r. <br /> Work will commence on or about U`/' .2o C for approximately <br /> 3 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 /> Sig�iature of Applicant: - Title Date <br /> MAS-ER_PS\FFRSCHLL (6,'M <br />