Laserfiche WebLink
APPLICA ΤΙΟΝ FOR ENCROACHMENT PERMIT <br />PLEASE PRINT: <br />Date <br />Το: San Joaquin County <br />Department of Public Works <br />Cι7'-f' OF Η,ιf�-,ι.Ξ"� <br />(Applicant Name) <br />(Mailing Address) s,: <br />Cfs337 (Ci[y, State, Zip Code) {Jόv 45t:,;-ιas.sz <br />(Area Code • Telephone Number) <br />OFFICE USE ONL Υ <br />JOB # 1 / ()φ (!) � REF # PS-2_ ()ο,,4/7 <br />ΑΡΝ iι.t ι -, ιο-,. , cR # <br />ΕχΡ.οΑτΕ _,-ιι ..... α-1�'-�Q�------=-___,,--νΑιιο 1l&Ι/').ο ΤΟ (,//Q/�D DRIVEWAYS: <br />STREET •C<� ... ,� 4 VtV\rlfAREA <br />ΤΥΡΕ <br />FORMS (v-f NOTES <br />Βf.λ:) 4ΙU6-L u. e,κ.e_ <::/,Η Α�7ι:CΑ-. <:;.-4,ι, F-----------------------------1 (Email Ad dress) <br />Sketch (Detailed plans may be submitted) <br />St::.ϊ?: A-r-t#ct-liΞ D ?t-.4-�ς-- <br />The undersigned hereby applies for permission to excavate, construct and/or otherwise encroach on County Hig�Right-of-Way on <br />the w'�s.-; side of Η'Υιιι..:.ι..e,'-( ΑνιΕ_,ιΑ,;;;-approximately /�ό' �ile AJOYZ..7/'f of Ιfι,,ο., /'2 ο _______ , by performing the following work (description of work): <br />ΝΟ::, ι...ι,..;..J � ��, .....::ι.G-A-r- ιS lk,.�� c,,- 7ί-J ι.Ξ <br />Work will commence on or after _�A_e_,.,=B��'-s_-r _______ for approximately 'Ρ-� ·Wcer1'.S-days. <br />1, the undersigned, certify that I am the owner of the respective property, or am qualified to represent the owner and agree to do the work described above in accordance with the rules and regulations of San Joaquin County and subject to inspection and approval. <br />�-�-�"ς_Q -CDD 'vew1':\ tΛn�c.."\Όα....Signare of Applicant · Title <br />Y:IFORMS & TEMPLATESIENCROACHMENT ΡΕRΜΠ APPLICATION.doc (08/08)