Laserfiche WebLink
APPLICATION FOR ENCROACHMENT PERMIT <br /> PLEASE PRINT: <br /> Date r OFFICE USE ONLY <br /> To: San Joaquin County JOB# 73jo- ? REF# <br /> Department of Public Works APN CR# <br /> n _ EXP.DATE 7-•!S"- 1 q <br /> 1_1����I A Y V !l✓Q c�- (Z ) 1(LE VALID -�$-�_ .�_2 0,(�TO �j-lS- 201y DRIVEWAYS: <br /> (Applicant Name) STREET � <br /> _ AREA S'fdC 'tc 7►,-QUAD CC C <br /> � <br /> (D C) E . 9 F)9 LI E� f ST TYPE S Cpl�Q <br /> (MailingAddress) FORMS <br /> NOTES <br /> K: O—A 9 5(�1-0 J - - — <br /> (City,State,Zip Code) <br /> 't L, Y —'S,3 I 1 <br /> (Area Code a Telephone dumber) <br /> Sketch(Detailed plans may be submitted) <br /> The undersigned hereby applies forpermission to excavate,construct andfor otherwise encroach on County Highway Right-of-Way on <br /> the L,��o+ side of ' F L�.e.� A (L-14- IV ao fee mile (-4� <br /> of 0") .ten a, (� �-� , by performing the following work( escription of work): <br /> Gk <br /> �7l� 0 <br /> L i:A ' x 3 <br /> Work will commence on or about L for ap ro ely 62() days. <br /> �')IM ' y \ <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 /> fK�U- (AA <br /> Signature of Applicant e Title ' Dat <br /> M:ICENRA(SERVICESCL621CAL1PU&SV.WKVAkS7IItPS)MCROACHMEIJTPERMRAPPLICA710HA0C(09113) 1 <br />