Laserfiche WebLink
APPLICATION FOR ENCROACHMENT PERMIT <br /> PLEASE PRINT: <br /> Dateu t-3_x iJ�, ®®Cf <br /> OFFICE USE ONLY <br /> To: San Joaquin County JOB #_ 73ao77 REF # <br /> Department of®Public Works APN CR # <br /> VALID, TO DRIVEWAYS <br /> .(Applicant Name) o STREET 3>ANA A& -rug- r*4 A 4,A6, Ee W <br /> 604#4 , <br /> AREA'9r4r 6;1W QUAD OS <br /> TYPE <br /> (Mailing Address) FORMS ! =11: Z' <br /> NOTE <br /> (City, State, .Zip Code) <br /> C � <br /> (Area Code - Telephone Number) <br /> Sketch (Detailed plans may be submitted) <br /> �_\ <br /> The undersigned hereby applies for permission to.excavate, construct and/or <br /> otherwise-encroach on -County..Highway Right-of-Way•oa the .\NSS- ..•• side;.of <br /> >A1approximatel <br /> of VA�1 A F'��i Y feet/mile �141ITC�1 S1lJE <br /> following work (description of:work) : ' r by Performing the <br /> WAIN -?IT-N' AC <br /> tiPPROX <br /> Wi�L1LT�R �ANA� �3L131v_ <br /> Work will commence on or,about -Q$-®$ • <br /> c7d� for approximately <br /> days.. , <br /> I, the undersigned certify that I am the owner' of. therespective -property, or am <br /> qualified to represent the owner and agree to do the work described above in <br /> accordance with the rule re9ulat3. of San Joaquin County and subject to <br /> inspection and approval. \,\.- i p s 13$ <br /> 35i ` C� S <br /> Signature of Applicant Title Date <br /> MASTER.-s>SkMs®L (6/00) . <br /> i <br />