Laserfiche WebLink
APPLICATION FOR ENCROACHMENT PERMIT <br /> PLEASE PRINT: <br /> Date C�c� \�}� �4 OFFICE USE ONLY <br /> To: San Joaquin County JOB# 73 Q KI REF# <br /> Department of Public Works APN CR# <br /> EXP.DATE <br /> I l -l S - I <br /> VALID ( - TO DRIVEWAYS: <br /> (Applicant Name) STREET Ka 5u ,e of <br /> AREA r QUAD �— <br /> - (o330 TYPE r <br /> (Mailing Address) FORMS 5 f� <br /> NOTES <br /> r t, <br /> (City,State,Zip Code) <br /> SSD c�D,) .43-t G <br /> (Area Code-Telephone Number) <br /> Sketch(Detailed plans may be submitted) <br /> 3*a <br /> � \ (00 <br /> The undersigned hereby applies for permission to excavate,construct and/or otherwise encroach on County Highway Right-of-Way on <br /> the Lr-� side of t� tii tZc� approximately i0 c�� �� �zc�o feet/mile f\+_L D'.z <br /> of ^ r, by performing the following work(description of work): <br /> W <br /> e WrLL rRusmao� Q wcwc? P� 1 S Ct ���G1v�c� c � ^x:Ewo'*_. <br /> %Ln <br /> Work will commence on or about tAl2v . f-!>---E - 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 /> �. C9'A- k4k <br /> Signature of icant- he Date <br /> M.ICENTRALSERVICESICLERICALIPUB-SV.WKWIASTER.PSIEN ACNMENLPERMITAPPLICATION.DOC (09113) q 0�5 4-OU' 0-7 1 <br />