Laserfiche WebLink
APPLICATION FOR ENCROACHMENT PERMIT <br /> PLEASE PRINT: <br /> ��✓✓rr' # { s5 <br /> Date / , o 1 OFFICS USE ONLY <br /> t <br /> To: San Joaquin County JOB #_72,49o-77 REF # <br /> Department of Public Works APNCR # <br /> Exp. DATE <br /> VALID. 5 f d O > I t DRIVWAYS: <br /> {Applicant Name) STREET ) �7 <br /> AREA r7 QUAD <br /> 1 S® ��4• e�� �9i �� TYPE <br /> ec(�Nailing�gAddreas) FORMS <br /> NOTE f <br /> (City,"State, .Zip Code) <br /> (Area Code - Telephone Number) <br /> Sketch (Detailed plans may be submitted) <br /> The undersigned hereby applies for permission to.excavate, construct and/or <br /> C� <br /> oche vise-encroa hon •Count Y•- Hi hwaY Ri ght-of-Way'--on•the <br /> Ex.Q/�'r• ' s'ide:•of <br /> 5 .approximately ( /mile <br /> of <br /> r eeby "performing the <br /> following work (description of:work) :C4 At <br /> Work will commence on or'about � :�•--�' for approximatel <br /> days• . y <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 rules, regulations 'of San Joaquin County and subject to <br /> inspection and approval. <br /> _ ,3 _ 1 <br /> Signature of Applicane Title Date <br /> MASRBR•PS\YBSS®L (6/00) - .. <br /> ',1 <br />