Laserfiche WebLink
APPLICATION FOR ENCROACHMENT PERMIT <br /> PLEASE PRINT: <br /> Date ` ja 2y71:Z OFFICE USE ONLY <br /> To: San Joaquin County JOB# 7.3a�5'� a.0 REF# <br /> Department of Public Works APN CR# <br /> (�., EXP.DATE 3 15 I2 <br /> t�'"�' UCG—,AC-7—WV VALID TO 3 l!5- IZ DRIVEWAYS: <br /> (Applicant N e) STREET dLL�/ De1 t/E <br /> 2--00 a _ O AREA !,14,/ QUAD 5W <br /> �( TYPE -E5 <br /> (Mailing Address) I FORMS W w, <br /> `e _ , ,� C , CA NOTES <br /> -e 51W <br /> Y�J (City,State,Zip ode) <br /> _I to � `T <br /> (Area Code-Telephone Number) <br /> Sketch(Detailed plans may be submitted) <br /> lv <br /> ��� <br /> The u dersigned hereby applies for permission to excavate,construct and/or otherwise encroach on County Highway Right-of-Way on <br /> the side of—"" 14'_. (4, 0 JrVV- approximately. (000 feet/m4e <br /> Of W_ by performing the following work(description of work): <br /> NCS �'.P�'�-C� � �1�7 D l F l cATl oN PduD NdN—Vtg l VF- <br /> 0 SU 01vS <br /> Co q1 1 cA�/A�l.o N <br /> ork will commence on or about 2 :2 for approximately — 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 /> ign ture of plicant-Title ate <br /> E:IPUMV.WIMOZTERPSOICROACHI.¢Irr PEW.Or APPUCNnO110OC(01M) <br />