Laserfiche WebLink
APPLICATION FOR ENCROACHMENT PERMIT <br /> PLEASE PRINT: <br /> Date ,'��7 2 OFFICE USE ONLY <br /> To: San Joaquin County JOB# 6r 0?1kO00s REF# <br /> Department of Public Works APN CR# <br /> EXP.DATE 10-IS-z 013 <br /> TOA D:v/IJ 'T,9 VALID 2o1_3 TO /0-15-2c>i25 DRIVEWAYS: <br /> (Applicant Name) STREET AgsiovL 2a- $ 0 S1, <br /> AREA QUAD G C- w <br /> v� o/0 TYPE <br /> (Mailing Address) FORMS SS/�l�T02-q <br /> �} NOTES <br /> o <br /> (City,State,Zip Code) <br /> (Area Code-Telephone Number) <br /> Sketch(Detailed plans may be submitted) <br /> S C � /�i—�e�-C11�/��;� /� ��� STv� �Lei-L�',M Cis'�' i��J � lii 1 i• <br /> �,� u,�nduclT <br /> Lk kb <br /> Yb11 <br /> The undersigned hereby applies for permission to excavate,construct and/or otherwise encroach on County Highway Right-of-Way on <br /> the side of approximately feet/mile <br /> of by performing the following work(description of work): <br /> Work will commence on or about '4 f• g for approximately /C:�' 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.PU&SV.WHIMASTER.PSIENCROACHMENT PERMIT APPLICATION DOC (01108) <br />