Laserfiche WebLink
APPLICATION FOR ENCROACHMENT PERMIT <br /> PLEASE PRINT: <br /> Date 9,/`s,/�� OFFICE USE ONLY <br /> To: San Joaquin County JOB# �f I/g� REF# <br /> Department of Public Works APN CR# <br /> EXP. DATE <br /> J �ofILLE,, L/ VALID /0 / DRIVEWAYS: <br /> (Applicant Name) STREET <br /> _ AREA 372L_-MA/ QUAD J(/� <br /> �Zg <br /> SEE TYPE S,m"Zk /.W1130al&454J7_ <br /> (Mailing Address) FORMS 5�lyl,,l, �W_� , eA�-c7 <br /> NOTES <br /> (City, State,Zip Code) <br /> fl- do/ 5 P ic, <br /> (Area Code-Telephone Number) <br /> Sketch (Detailed plans may be submitted) <br /> The undersigned hereby applies for permission to excavate,construct and/or otherwise encroach on County Highwa Right-of-Way on <br /> the �A� side of tGGoX approximately ,o ' f /CGyi�di�I <br /> of�r,�-� /�a4x� 53s:3 �c,E—rte , by performing the following work(description of work): <br /> Sil.�wi9GK /yLIG�.�(lE✓nE,nTFIS ��,9-��Gbf/ �5 <br /> Work will commence on or about / 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 descr' above in accordance with the rules and regulations of San Joaquin County and subject to inspection and approval. <br /> ��c - J24_1q't-0'( �//?h/�- <br /> Signature of Applicant-Title 5j- r r/7'-dC`/, Date <br /> YIFORMS&TEMPLATESIENCROACHMENT PERMIT APPLICATION.Ax(08/08) <br />