Laserfiche WebLink
APPLICATION FOR ENCROACHMENT PERMIT <br /> PLEASE PRINT: <br /> Date OFFICE USE ONLY <br /> To: San Joaquin County JOB# �,1 gob REF# <br /> �ep_art_my t of Pu lic orks ( APN _ CR# <br /> EXP.DATE -?-01 q'60 P-M <br /> VALID Z -Z,YD TO - [ DRIVEWAYS: <br /> (Applicant Name) STREET C11 V.1,5SCCKK32 ' <br /> AREA QUAD <br /> -7 TYPE I r <br /> (Mailing Address) FORMS %LJ 2q <br /> NOTES <br /> (City, State,Zip Code) ?-- <br /> Z � ? -i -7 -1 <br /> (Area Code-Telephone Number) <br /> 2.b Li -T t 4p143 & C—`( <br /> Sketch(Detailed plans may be submitted) <br /> The undersi ned hereby applies for permission to excavate,c nstruct and/or otherwise encroach n County Highway Right-of-Way on <br /> the Ccti. side of laSS G +2.A. approximately_ feet/mile 11-6G- <br /> 4,.,j <br /> 1-61— <br /> y 12— vby performing the following wor (description of work): <br /> (e,c. - G'v+ i 4 t,+ v-r--a «- s , r <br /> Work will commence on or about I va for approximately t 7---- ti�--r 4ar. <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 /> ta <br /> Si nature of Applicant-Title Date <br /> VIFORMS_ , <br /> S_TEM.P_IA�U�ACW NTPEHtaTAPPUCAi�{J.doc(0m) r - <br />