Laserfiche WebLink
APPLICATION FOR ENCROACHMENT PERMIT <br /> 4-00 4-qi <br /> PLEASE PRINT: <br /> Date OFFICE USE ONLY <br /> � ,� �.. <br /> To: San Joaquin County JOB# ZREF <br /> j — REF - --- ' <br /> Department of Public Works APN CR# i <br /> EXP.DATE <br /> J, <br /> tt f, p DRIVEWAYS:VALID TO <br /> - <br /> (Applicant Name) STREET <br /> AREA QUAD = , _— <br /> C TYPE — <br /> (Mailing Address) FORMS <br /> NOTES <br /> (City,State,Zip Code) <br /> (Area Code-Telephone Number) <br /> Sketch(Detailed plans may be submitted) <br /> The undersigned hereby applies for permission torgccavate,construct and/or otherwise encroach on C ounty Highway Right-of-Way on <br /> the _side of__16-: % 'K-on. approximately Z-C 0 feet/mile t-of I-,t 1 a;: I- k1 ,.a, by performing the following work(description of work): <br /> '0 <br /> Work will commence on or about . >• r". r' 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 subjeGI to inspection and approval. <br /> z � <br /> Signature oLAWlicant-Title l ' Date <br /> 61 t11_141 PAL fH'rSIcJ[.(ii;•:t;Htf(VT PERW KPi.CA?LOW DL•_ (D3113) <br />