Laserfiche WebLink
APPLICATION FOR ENCROACE4ENT PERMIT <br /> PLEASE PRINT• <br /> Date <br /> OFFICE TISK ONLY <br /> To: San Joaquin County <br /> JOB REF # <br /> Department of Public Works APN CR' # <br /> EXP. DATE <br /> VALID "t�t- TO -O <br /> DRIVEWAYS: <br /> (Applicant Name) I,' STREET �•GG' <br /> y AREA S?ct'. i✓QUAD <br /> 1 tt r t" L otic �r- TYPE <br /> .(Mailing Adj(dress) E FORMS <br /> NOTE <br /> (City, State, Zip Code) <br /> (Area Code - Telephone Number) <br /> Sketch (Detailed plans may be submitted) <br /> 4- <br /> The undersigned hereby applies for permission to excavate, construct and/or <br /> otherwise encroach on County Highway Right-of-Way on-the i }h .,side of <br /> approximatelY� /mile <br /> of o ' <br /> byperforming the <br /> following wor' (description of work) : _ <br /> r- ,� <br /> Work will commence on or about _ for approximately <br /> days. i <br /> t r <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 Applicant - Title 1 Date / <br /> MASTER.PS\PE3S0tDL (6100) <br />