Laserfiche WebLink
i <br /> APPLICATION FOR ENCROACHMENT PERMIT <br /> PLEASE PRINT: <br /> 1400 3 q <br /> Date ; - ��- OFFICE USE ONLY <br /> To: San Joaquin County JOB# 11000 5_ REF# <br /> Department of Public Works APN Ds -W) —L CR# <br /> EXP.DATE <br /> tv. VALID TO DRIVEWAYS: <br /> (App scant Name) STREET -f <br /> AREA 2 QUAD _ <br /> Z La S S ►�(�f �, TYPE 1-14 <br /> (Mailing Address) FORMS ��jy/ ^Z q <br /> NOTES <br /> (City,Stale,Zip Code) <br /> (Area Code a Telephone Number) <br /> Sketch(Detailed plans may be submitted) <br /> NNS,-- <br /> See PA � �1 <br /> The undersigned hereby applies for ermission to excavate,construct and/or otherwise encroach on County Highway Right-of-Wa on <br /> the �ot�`�1� side of 1�a t��� a� approximately \Sd5 feet/mile �_a� <br /> of S�-r'a S;A ,by performing the following work(description of work): <br /> Work will commence on or about \—2 2`— 1 4 for approximately 1 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 e Tie pate <br /> M:ICENTR7d IWCESICLERICALIW&SV.WKUd STEL%aCROACHMENTPERMITAPPLICATION.DOC (09113) <br />