Laserfiche WebLink
� oU <br /> o-7 t,- Sb D <br /> APPLICATION FOR ENCROACHMENT PERMIT <br /> PLEASE PRINT: <br /> Date Ll L OFFICE USE ONLY <br /> T, <br /> To: San Joaquin County JOB# 7��'Z REF# <br /> !! L Depart/m-e-nt of Public Works / APN CR# <br /> .e U+ z �..!` V'Ad /\`+� VALID ATE 9- -(� TO //�_ -�. <br /> DRIVEWAYS; <br /> p(Appli ant Nae) STREET J <br /> 0.10 �c y .Yw . � 0.0 ST(, �J AREA L1� ,'�- <br /> � QUAD IYF <br /> TYPE -- <br /> (Mailing Address) FORMS 5 <br /> NOTES <br /> (1J4e,+ eCVq, � <br /> (City,State,Zip Code) <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 Highway Right-of-Way on <br /> the side of approximately . feet/mile <br /> of ,by performing the following work(description of work): <br /> Q 6d,.G .�',1� �� ie��a���r q t o�� r�o le <br /> Work will commence on or about -71-111,4- 101 14, 77H 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 subject to inspection and approval. <br /> "Sig ure of Applicant-Title bate <br /> ETU9-SV.4YKV:ASTERPSTEttCROACH!!EIlTPERl,IRAPPLICAT1011.DOC_(01109) <br />