Laserfiche WebLink
APPLICATION FOR ENCROACHMENT PERMIT <br /> PLEASE PRINT: <br /> Date <br /> OFFICE USE ONLY <br /> To: San Joaquin County JOB# <br /> Department of Public Works -�� REF# <br /> A9$ 1 APN <br /> Gri>JE VALID ATE CR# <br /> ///s� <br /> (Applicant NameZS T /S I DRIVEWAYS: <br /> STREET AV' D, <br /> AREA -6'1 QUAD <br /> TYPE �1,t_ (4d-� •-- <br /> (Mailmg Address] FORMS <br /> 17t i'TS�il Q T�,j1 C1r��� NOTES 6 15 <br /> (City,State,Zip Code) <br /> q2 755— JoDg <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 Hig Right-of-Way on <br /> the Mo side of C'- <br /> of _i,. approximately <br /> • K�2U P1� ee ile <br /> by performing the following work description of work): <br /> ofelm <br /> i <br /> Work will commence on or about i IVt , <br /> �- 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 /> —j;gnature of Applicant• title h�l� <br /> Date <br /> MICEMRAMWCE=eW-4GLW&SVWWASMPUNCAORZu TPERMITAPRAGAT*q DOC(0U) . <br />