Laserfiche WebLink
APPLICATION FOR ENCROACHMENT PERMIT <br /> PLEASE PRINT• <br /> Date � � � <br /> OFFICE USE ONLY <br /> To: San JoagLir. County JOB ## L3�j9 REF <br /> Department of Public Works APN CR # <br /> _ EXP, DATE <br /> t y 1^ VALID 2 /I <br /> O DRIVEWAYS: <br /> (Applicant. Name) STREET xf <br /> AREA rG(`y QUAD �_ <br /> t�-tGN i` rV�iLt 1�D. TYPE �cu�lts 1So✓>•s <br /> (Mailing Address) FORMS <br /> NOTE <br /> %3C.� ct S �.r v <br /> (City, State, Zip Code) <br /> ok, - '--k-)q- .q--1 ay <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 /> otherwise encroach on County Highway Right-of-Way on the � 114� <br /> G�r .1T L;tlt Rim, side of <br /> approximately feet/tea iN <,,; <br /> following work (description of work) : 30 jLt E�t~Jt ;_y c,i '. by Performing the <br /> u;,I sI S o.= y er L-"-46 i4_ ,.i 5 t�ov Vii=\L <br /> i y"C?C �D Y i c'�c tL t <br /> CY1 Yom►T". v..LiZI✓_ t� � LA_ <br /> �"'� �1S 1� A*-1 ►}� �j` �-`{>�.0 UT if c Cc�-r1�L,FJ.-a�j __ PSE.%�S�. c-'1C'E C� f [Z <br /> Work will commence on or about <br /> ycz�, days. for approximately <br /> I, the undersigned certify that I am the owner of the respective 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 /> Signature of Applicant - Title <br /> Date <br /> MASTRR.PS\FERS,7ML (6/00) <br />