Laserfiche WebLink
APPLICATION FOR ENCROACHMENT PERMIT <br /> PLEASE PRINT: <br /> Date 1 -• 15 - / y OFFICE USE ONLY <br /> To: San Joaquin County JOB# j (� Q S REF#i <br /> Department of Public Works APN CR# <br /> EXP.DATE I Z -L-L <br /> DRIVEWAYS: <br /> TO <br /> VALID 1( -1± - l <br /> (Applicant Name) STREET a( <br /> _ AREA 54 QUAD <br /> TYPE --6-0j% <br /> (Mailing Address) FORMS C S W Z <br /> NOTES <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 ht-of-WaY on <br /> the LuE5,T side of A� 1,-ZT F-'- approximately 3c� fee ile , <br /> of C_NE5�-pi�E'��; �Ic��-!!=T� by performing the following work(descnp ion of work): <br /> Work will commence on or about j Q-- (p 14 for approximately da <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 /> A <br /> ri-a—turt of Applicant-Title Date <br /> M`CE^i':.ALS`cPVICE5iCL`P CAIPt:sSU'NNIMASTE3.PSc`4CrtCACIIIENTPE;?MITAPLICAT')I 111 (09/13" <br />