Laserfiche WebLink
APPLICATION FOR ENCROACHMENT PERMIT <br /> PLEASE PRINT: <br /> Date /C}! OFFICE USE ONLY —� <br /> To: San Joaquin County JOB# L,3A5t5—;R- REF# <br /> Department of Public Works APN _ CR# <br /> EXP.DATE 5ilhl <br /> VALID TO _� DRIVEWAYS: <br /> 2_ ^ (Applicant Name), STREET = <br /> AREA <br /> I V C (,Ja ' �Y'iac l � TYPE � QUAD --— <br /> y� <br /> (Mailing Address) FORMS <br /> 3772 0 _ NOTES <br /> L <br /> tarty,state,Lip coa4?) <br /> (Area Code-Telephone Number) <br /> Sketch(Detailed plans may be submitted) <br /> The undersigned hereby applies for permission to excavate,construct and/or otherwise encroach on County Highway Ri ht-of-Way on <br /> the ��'v -4L, side of /I, c-Al}-� � 2 r i, approximately c , .i� fee ile L, (7, <br /> of n by performing the following work(descfiip ion of work): <br /> r <br /> Work will commence on or about for approximately f b !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 /> -Signature of Applicant-Title Date <br /> E''PVBSV`Ni(UWSTER PSFNCRp.ACNMENT PERM'OPUCAT.ION.DOC (O-Mg,' <br />