Laserfiche WebLink
APPLICATION FOR ENCROACHMENT PERMIT <br /> PLEASE PRINT: <br /> Date 9— `5 — / q OFFICE USE ONLY <br /> To: San Joaquin County JOB# j ( �S REF# <br /> Department of Public Works APN CR# <br /> EXP.DATE DRIVEWAYS: <br /> (S�VQC-0 ) VALID _1 - -I� TO - <br /> (Applicant Name) STREET d( <br /> AREA5 � I� QUAD <br /> 13rz' IS 4 r TYPE d 0 <br /> (Mailing Address) FORMS S S W Z <br /> NOTES <br /> (City,State, Zip Code) <br /> 12 7 <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 i ht-of-WaY on <br /> the ly��>T side of Ab 4177 Ff7 approximately �,r7 fee ile <br /> of (;WE,r ?� �!`c .l�=f�%�� by performing the following work(descnp ion of work): <br /> G>4`T / <br /> Work will commence on or about j 0— (,o-- 14 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 /> Fr-,tom" r 1 Cooro <br /> Sign'aturf of Applicant-Title Date <br /> M'C''c`!"+',4LSE:?`fCESCLEP:CALIP,;35V WKIAL45-rZ.FSL-vC.-AC'n4EN11E=MIT APPLiCA?'IONDCC (09/13) <br />