Laserfiche WebLink
APPLICATION FOR ENCROACHMENT PERMIT <br /> PLEASE PRINT: <br /> Date 7/10/14 OFFICE USE ONLY <br /> To: San Joaquin County JOB# !t 00 S REF# <br /> Department of Public Works APN CR# <br /> EXP.DATE ' <br /> Calaveras Telephone VALID TO _ S - (4 DRIVEWAYS: <br /> (Applicant Name) STREET C 1,1 JnIA- <br /> AREA QUAD ` <br /> 513 Main Street TYPE G I <br /> (Mailing Address) FORMS <br /> NOTES <br /> Copperopolls,CA 95228 <br /> (City,State,Zip Code) <br /> (209)785-2211 <br /> (Area Code-Telephone Number) <br /> Sketch(t)etalled plans hi ay be su.bmlUed) <br /> The undersigned hereby applies forpermission to excavate,construct andfor otherwise encroach on County Highway Right-of-Way on <br /> the east side of Shelton Rd approximately,- 2.100' feeymile <br /> of ,.by performing the foilowing work(description of work): <br /> Attachf i ADSS fiber to existing Jornf pales along Shelton R:d/N Shelton Rd. __.. <br /> Work wiil commence on or about far appro dmatefy. 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 /> YSfgn ture of Applicant-Title Date <br /> MiCritTRALMRNG_S.,F-�VCALFI!5,WW iMASTFRP5K11CfOXIWA-'fRPFS&gr APPt[Gi M!ID00 W11) <br />