Laserfiche WebLink
APPLICATION FOR ENCROACHMENT PERMIT <br /> PLEASE PRINT: <br /> Date MAE , <br /> OFFICE USE ONLY <br /> � � <br /> To: San Joaquin County JOB # ��C�JL- REF # <br /> Department of Public Works APN CR' # <br /> L-5-7/1-1 r" EXP. DATE 7-/-;7­021�t :; L_- t <� , VALID11-0 TO DRIVEWAYS <br /> (Applicant Name) STREETG�`1E+� �. <br /> AREA Z-119' PUAD .rV <br /> "��.✓ IG _� n _ TYPE [l l>E- <br /> (Mailing Address) FORMS �'�� <br /> -NOTE <br /> (Cit§, Sto , Zip -Code) -- <br /> � !2 - <br /> - <br /> (Area_Code_.--._Telephone Number.) <br /> Sketch (Detailed plans may be submitted) <br /> TRAFFIC CONTROL PLAN <br /> SHALL BE AS PER <br /> CURRENT M.U.T.C.D. <br /> CALIFORNIA SUPPLEMENT <br /> The undersigned hereby applies for permission to excavate, co. struct and/or <br /> — id ofo rwi encroa on County- Highway Right hfeet/zal�e- <br /> approximat <br /> of by -performing the <br /> folpying work (desc ;iption of work) : <br /> Work will commence on or about for approximately <br /> 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 ec n and approval. <br /> Signature of ApplicFant - Title Date <br /> LZ 0i 7 <br /> MUTER.PS\FEES®L (6/00) <br />