Laserfiche WebLink
APPLICATION FOR ENCROACHMENT PERMIT <br /> PLEASE PRINT: <br /> Date 0 9/ O � <br /> / OFFICE USE ONLY � <br /> To: San Joaquin County JOB# pOp� REF# <br /> Department of Public Works APN —— <br /> CR# <br /> EXP. DATE , �p,08 <br /> VALID O,® TO + ,Q DRIVEWAYS: <br /> (Applicant Name) STREET <br /> I/AR 06tS <br /> AREA <br /> TYPE 2uit,� Ey 01 — TQg <br /> (Mailing Address) � ' �"� <br /> FORMS77:: <br /> NOTES <br /> s T _3 s' <br /> City,State,Zip Code) <br /> (Area Code-Telephone Number) --- _ <br /> [Sketch (Detailed plans may be submitted) <br /> The undersi ned hereby applies for permission to @A@aaate, seu=tc or otherwise encroach on County Highway Right-of-Way on <br /> the side of approximately a roximatel <br /> of pp Y feet/mile <br /> by performing the following work (description of work): <br /> e:"e-- fit c�E..f .4i C yr[ R idJ AUoT X,.g C g <br /> 0&41– T.QA/'/^/G�eq, .�s t <br /> y VENT <br /> 1. OD f'i�Z VD<viJ TEl2 sh'i9 L &L2Z4 L �— <br /> OROfy7-e <br /> Work will commence on or about d 1�7,p f <br /> or 41414"=&4y _ dayg. <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 /> VO G v.VTf f/2 <br /> IEVEiu i <br /> Signature of Applicant-Title <br /> Date <br /> ('.PUB SV 6K`.M ASII N PS1 Nk 130A(:HML NI PUItMII APPI ICATION.DOC (01106) <br />