Laserfiche WebLink
APPLICATION FOR ENCROACHMENT PERMIT <br /> PLEASE PRINT; <br /> Date Ar(AL't OFFICE USE ONLY <br /> To: San Joaquin County JOB# 2L 0 Z( 3 REF# <br /> Department of Public Works APN CR# <br /> EXP.DATE f(,- "I- /,57 . <br /> C4T v or- -rfl k� VALID �- ( -( TO - - DRIVEWAYS: <br /> (Applicant Na ) STREET /�f(,,Ir ' <br /> AREA <br /> TYPE <br /> litVA(- beW�� �Z� -�r'-�—_.. QUAD <br /> (Mailing Address) FORMS Q Z 1 3q <br /> NOTES <br /> 'S LY CA g 5��7w <br /> (City,State,Zip Code) <br /> b-�I- tp y 5?�7 <br /> (Area Code-Telephone Number) <br /> Sketch(Detailed plans may be submitted) <br /> C A L q <br /> The undersigned hereby applies for permission to excavate,construct and/or otherwise encroach on County Highway X <br /> t-of-Way on <br /> the_�1 ' side of approximately <br /> of- ,Qq 1&3Cbl -VII? t,d 4 kl ,by performing the following work(description of work): <br /> __L}] e-.,PAA- 14- �Gk4 b 1 D fnt'A�-r'- G�ol.- *-N t-j\ ag:L <br /> Work will commence on or about—M) 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 /> Signature o Applicant-Title Date <br /> uuarrxuscFsc _wussv.Kxuasm� caorsrte�auraaaucnrweooc P&» <br />