Laserfiche WebLink
APPLICATION FOR ENCROACHMENT PERMIT <br /> PLEASE PRINT: <br /> Date OFFICE USE ONLY <br /> To: San Joaquin County JOB # '' ✓( REF # <br /> Department of Public Works APN CR # <br /> EXP. DATE a-kS-Dq <br /> VALID ice:k-09 TO aL-;.5-09 DRIVEWAYS: <br /> (Applicant Name) STREET kkSSLMrP\ A32 <br /> AREA QUAD <br /> TYPE Cfl► i, M CEki�� <br /> (Mailing Address) FORMS W'6, aCr" <br /> NOTE <br /> (City, State, Zip Code) <br /> (Area Code - Telephone Number) <br /> Sketch (Detailed plans may be submitted) <br /> I <br /> The undersigned hereby applies for permission to excavate, construct and/or <br /> otherwise encroach on County Highway Right-of-Way on the side of <br /> approximately :feet/mile <br /> of by performing the <br /> following work (description of work) . ,' ,P <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 +:he 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 Date <br />