Laserfiche WebLink
APPLICATION FOR ENCROACHMENT PERMIT <br /> PLEASE PRINT: <br /> r <br /> Date ; ,' ✓ I; OFFICE USE ONLY <br /> To: San Joaquin County JOB# /DDfJ REF# <br /> Department of Public Works APN CR# <br /> EXP. DATE / f/ <br /> VALID TO DRIVEWAYS: <br /> (Applicant Name) STREET <br /> AREA QUAD <br /> c}. f tt r �t ✓ s'1 <br /> TYPE ,RE�— i/401�C1 � <br /> (Mailing Address) FORMS5— �1 <br /> NOTES <br /> (City,State,Zip Code) — <br /> u <br /> (Area Code-Telephone Number) -- <br /> Sketch (Detailed plans may be submitted) <br /> JL ?>YIl ¢ r!' f;? 0 xlf1)d ° i <br /> LvjU '�' <br /> The undersigned hereby applies for permission to excavate,construct and/or otherwise encroach on County Highway Right-of-V on <br /> the u e s r side of l0Pr�s ti ;�t„ AL.e�Ue approximate) �. d�� <br /> Y feet/mile �- <br /> ofCv �1fr C t / 4- �,�,�� � Aven�4,by performing the following work(description of work): <br /> ts2_ l�zU �, y anJ(9q4 z 1-k-0 U.2 <br /> Avein,e CAnd <br /> ►1 �!>tcvi { I� Lill t -,,d <br /> Work will commence on or about for approximately <br /> 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:1PN&SV.WNIMASTER.PSIENCROACHMENT PERMIT APPLICATION DOC (01108) <br />