Laserfiche WebLink
APPLICATION FOR ENCROACHMENT PERMIT <br /> PLEASE PRINT: <br /> Date OFFICE USE ONLY <br /> To: San Joaquin County JOB# REF# <br /> Department of Public Works APN CR# <br /> EXP.DATE 3/ Iz <br /> \ VALID O DRIVEWAYS: <br /> (Applicant Name) STREET ,Q L� Q�, <br /> AREA QUAD _ <br /> �J L(11I`11I� �'Ur�1�5 TYPE /�✓ <br /> (Mailing Address) FORMS <br /> r NOTES <br /> (City,State,2ip Code) <br /> (Area Code-Telephone Number) <br /> Sketch(Detailed plans may be submitted) �+ 1 <br /> S'e-p— Awo'-L\M�t V-�-\ C- cicl� <br /> The undersign tl h eby applies for pPermiss n to excavate,co struct ntl/or otherwise encroach on County Highway Right f-Way on <br /> the „ side of H as I VA ,�t� approximately��SaQ' _feet/mile <br /> of vw FL G6-5- V'1Zo' performing the following work(description of work): <br /> kc� s W16.; Te. Ve lace- e 5fi <br /> kAk 4.- bw l <br /> w <br /> Work will commence on or about O1 for approximately I SQ 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 accordsQcewith the rules and regulations of San Joaquin County and subject to inspection and approval. <br /> R <br /> -10 Id 3C —T) I I , <br /> Signature of Applicant-Titl Date <br /> E ftESV WKNASTERPSIENCROACHMENT PERMIT APPLICATION DOC (01/09 <br /> F 0 r 14 V S <br />