Laserfiche WebLink
� �ot� c.c�e✓1 CA S i;� <br /> APPLICATION FOR ENCROACHMENT PERMIT <br /> PLEASE PRINT: <br /> Date I L J– OFFICE USE ONLY <br /> To: San Joaquin County JOB# �w�Ct � REF# <br /> Department of Public Works APN CR# <br /> EXP.DATE <br /> IJGO % C N 2l S � r!z VALID (( TO – – DRIVEWAYS: <br /> (Applicant Name) STREET <br /> `1 AREA QUAD S <br /> 63 7d 54151 S7o TYPE " <br /> (Mailing Address) FORMS SS t <br /> NOTES <br /> (City,State,Zip Code) <br /> �2-5J -7ff,5 - X77 <br /> (Area Code-Telephone Number) <br /> Sketch(Detailed plans may be submitted) S616 A TT ASN <br /> The undersigned hereby applies for permission to excavate,construct and/or otherwise encroach on County Hi g Right-of-Way on <br /> the AtO Z'rg side of A). M4—it-Mw 6, 2'!>. approximately qQQ eet/ ile GU&S�1 <br /> of MA6JDA 9:Y aZt� F26/.)C,N C-4m , by performing the following work(description of work): <br /> gjQ.Q.cf:R_1JA.4 �klST/NC G,4 I V VA L'E 10 <br /> _/N 6i A L L /- 2- EJ1L CATV S6r&yl C6 <br /> Work will commence on or about ( 1– '24 – 1y for approximately : S 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 /> zk 7-1v <br /> S nature of Applicant-Title Date <br /> M ICENTRALSERVICESICLERICALIPU&SV WKWIASTER.PSIENCROACHMENT PERMIT APPLICATION.DOC (09113) <br />