Laserfiche WebLink
APPLICATION FOR ENCROACHMENT PERMIT <br /> PLEASE PRINT: <br /> Date _ A 0 OFFICE USE ONLY <br /> To: San Joaquin County JOB # REF # <br /> Department of Public Works APN CR # <br /> EXEC ``. DATE -17-D6 <br /> L✓ N `�J � j ( ,�(!j ) ;N1Wl VALIDTO -/7-08 DRIVEWAYS: <br /> (Applicant Name) STREET <br /> AREA 11,VVeO QUAD <br /> td TYPE ?T- <br /> ,�� 'J9lJ✓ <br /> n (Mailing Address) FORMSi.✓u/ <br /> C 6 NOTE <br /> / (City, State, Zip Code) <br /> (Area Code - Telephone Number) <br /> Sketch (Detailed plans may be submitted) <br /> The undersigned hereby applies for permission to .excavate, construct and/or <br /> otherwiseencroachon County Highway Right-of-Way on-the N0971+ side_of - <br /> FrZo i_ ST, approximately feet/mile <br /> of by "performing the <br /> following work (description of work) : Ffntn ,IT 5T- &6`1VQ,_-ee4 <br /> M/a-►21u�"r 5 T . N �'1�s .moo L�u tic Atv fLo o ti vot�s r 2 vvi <br /> Work W,1-11 commence on or about v L:7 2_000 for approximately <br /> ONE 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 /> pta-s/ 40 -08 <br /> Signature of Applicant - Title Date <br /> MASTER.PS\FBBSC'BDL (6/00) <br />