Laserfiche WebLink
APPLICATION FOR ENCROACHMENT PERMIT <br /> PLEASE PRINT: <br /> Date _ AZ-0111 OFFICE USE ONLY <br /> ���5`01^� <br /> To: San Joaquin County JOB# REF#CR# <br /> Department of Public Works APN <br /> �c EXP.DATE /Z <br /> L VALID !/ 0 / !2 DRIVEWAYS: <br /> (Applicant Name) STREET • ,�!`b�/�t'` + <br /> AREA ,1I�A1 QUAD <br /> n TYPE �Es. <br /> r� FORMS S �/<✓ -2-1' <br /> Mailing Address) <br /> NOTES <br /> T (City,State,Zip Code) <br /> tea) 3 LE7-61 y 1 <br /> (Area Code-Telephone Number) <br /> Sketch(Detailed plans may be submitted) <br /> S-eP s 40 1A. <br /> IFY0-4t <br /> l�f o �O�.p L.wSu✓1.F S �llvw6� <br /> The un�elined hereby applies forpermission to exc vate,construct and/or otherwise encroach o County High&eeile <br /> ight-of-Way on <br /> the oside of w • o approximately � 5-d W6S7— <br /> th /E,(L by performing the following work(description of work): <br /> of <br /> SEG Sd <br /> Work will commence on or about 2d for approximately /jyo 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 /> a_&" M R,ec06::. -- ;�s f l' 7-ZO- I 1 <br /> -signature of Applic t-Title Date <br /> EPU&SV.WKNASTER.PSENCROACNMENT PERWAPPUCA71ON DOC(01M) <br />