Laserfiche WebLink
APPLICATION FOR ENCROACHMENT PERMIT <br /> PLEASE PRINT: <br /> Date f //C OFFICE USE ONLY <br /> To: San Joaquin County JOB# �3�—�_ REF# <br /> Department of Public Works APN CR# <br /> EXP.DATE <br /> 9 5 9 / VALID TO s/ /3 DRIVEWAYS: <br /> (Applicant Name) STREET <br /> AREA <br /> QUAD _/t/� <br /> 7�i Vl C re- TYPE 6L.E �PL�4GE/,✓�.�. <br /> (Mailing Address) FORMS <br /> / NOTES <br /> C 7-0 9— —CAI r/S 2 3 <br /> (City,State,Zip Code) <br /> �2 G'`%) % -- li <br /> (Area Code-Telephone Number) <br /> Sketch(Detailed plans may be submitted) <br /> E A 7-7,-Cq E'P IZ–,4�5 <br /> The undersigned hereby applies for permission to excavate, construct and/or otherwise encroach on County Highway Right-of-Way on <br /> the fAs r side of I approximately ee mile <br /> Of L P, _ zr�,��, S/� l� ),��' , by performing the following work description of work): <br /> Work will commence on or about Z / for approximately 9/-2 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 /> Signat4otf--Applicant-Title Date <br /> E:IPU&SV.WKIMASTER.PSIENCROACHMENTPERMIT APPLICATION.DOC (01/08) <br />