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 •/ c�$ <br /> VALID TO /5 DRIVEWAYS: <br /> (Applicant Name) STREET <br /> AREA Ti QUAD _ <br /> TYPE �^i l Z'� Y-2 <br /> (Mailing Address) FORMS <br /> NOTES <br /> (City, State,Zip Code) <br /> (Area Code-Telephone Number) <br /> Sketch (Detailed plans may be submitted) - <br /> 75 <br /> 1 <br /> Y ' <br /> f <br /> The undersigned hereby applies for permission to excavate, construct and/or otherwise encroach on County Highwa Right-of-Way on <br /> the �'-side of L AA" s ���t approximately ;fee <br /> of �a '� by performing the following work(description of work): <br /> At <br /> Work will commence on or about for approximately days. <br /> I, the undersigned, certify that I am the owner of the respective property, or am qualified to represent the owner and agree to do the <br /> work described above in accordance with the rules and regulations of San Joaquin County and subject to inspection and approval. <br /> 'L k <I \-15' \..J I✓V,l 1�tXV`moi k n /^� / +y. <br /> Signature of Applicant-Title Date <br /> E:IPUB-SVWMMASTER.PSIENCROACHMENT PERMIT APPLICATION.00C (01/08) <br />