Laserfiche WebLink
APPLICATION FOR ENCROACHMENT PERMIT <br /> PLEASE PRINT: <br /> Date _' ',' �%f OFFICE USE ONLY <br /> To: San Joaquin County JOB# REF# <br /> Department of Public Works APN CR# <br /> / ! EXP.DATE <br /> �r-tc - / ' =-s ,' G VALID / 0 DRIVEWAYS: <br /> (Applicant Name) STREET <br /> AREA --fA44QUAD h1 <br /> TYPE o <br /> (Mailing Addr s) FORMS <br /> NOTES <br /> (City,State,Zip Code) <br /> (Area),.;ode-Telephone Number) <br /> Sketch(Detailed plans may be submitted) <br /> The undersigned hereby applies for permission tq excavate, ns uct and/or otherwise encroach on County Highway Right-of-Way on <br /> the si of f✓lr e a approximately 7 3 4 P feetic S <br /> of_tL:.c ,-x by performing the following work(description of work): <br /> tri S f�` � , r A,�—L^�Gd� je�,i a s'a !�o•cL"-�(� r7i'�<ra s'';�°t'',✓' �-�'�'d , a.v t e:-r' '�`C.� <br /> Work will commence on or about_ Z zc:.'� for approximately/h-,-7 1.ra r 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 accQrdsiic`e with the rules and regulations of San Joaquin County and subject to inspection and approval. <br /> Signature of Appli nt-Title ate <br /> F PUB SWIVKWASTER.PSCNCROACF-1EN7 PFRMITAPPUCATJON.DOC puiz) <br />