Laserfiche WebLink
APPLICATION FOR ENCROACHMENT PERMIT <br /> PLEASE PRINT: I <br /> Date / 1 I OFFICE USE ONLY <br /> To: San Joaquin County JOB# REF# <br /> Department of Public Works APN CR# <br /> EXP.DATE <br /> A 12 L A g S S l; S VALID 2 y TO DRIVEWAYS: <br /> (Applicant Name) STREET <br /> AREA G QUAD 5Gt/ <br /> S—, t /2;- TYPE <br /> (Mailing Address) FORMS <br /> NOTES <br /> _ Fes &iA LrS-63y <br /> (City,State,Zip Code) <br /> 'iU --t C79 <br /> (Area Code-Telephone Number) <br /> Sketch(Detailed plans may be submitted) <br /> The undersigned hereby applies for permission to excavate,construct and/or otherwise encroach on County Highway Right-of-Way on <br /> the h�,Ji, side of k" I approximately_ acv ee mile L,H s t <br /> of -tr{;,;+-tc S by , by performing the following work(description of work): <br /> F - <br /> - T t.. <br /> <. .-tom -A r-..�.� ,�� C.n <:.��.t 1, <,J. <br /> Work will commence on or about h t��,,,t,t:- 2 ori_ 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 /> l/Z <br /> Signature of Applicant-Title Date <br /> E:1PUB-SV.WKLMASTERP$IENCROACHMENTPERMRMPUCATION.DOC(01108) <br />