Laserfiche WebLink
APPLICATION FOR ENCROACHMENT PERMIT <br /> PLEASE PRINT: <br /> Date 0 'a OFFICE USE ONLY <br /> To: San Joaquin County JOB# r( 0(9 0 S REF# <br /> Department of Public Works APN CR# <br /> EXP. DATE <br /> Ou (V"J 11-C,C-1 VALID TO DRIVEWAYS: <br /> (Applicant Name) STREET HW X 2 <br /> n AREA QUAD <br /> l"• - ` ®'r f( � TYPE <br /> (Mailing Address) FORMS 11/ <br /> y� NOTES <br /> ,J 1 1Cc°✓i e ti- <br /> (City, State,Zip Code) <br /> (Area Code-Telephone Number) <br /> Sketch(Detailed plans may be submitted) <br /> _ <br /> �\.S ,��ctCIAC(. '^-� �a ��1\ �S ��s r Co v& r�e.'� <br /> The undersigned hereby applies for permission to excavate,construct and/or otherwise encroach on County Highway Right-of-Way on <br /> the Pa-6- side of AoJm C— tZe 3*� \ I& approximately 20 +-o 4-6feet/mile Fc�� <br /> Of lR®�'k-4?-- (-.V _ by performing the following work(description of work): <br /> +►n®(� <br /> Work will commence on or about AA&,rc k o2-. ;�o o %- for approximately ���s days. <br /> J <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 /> D <br /> d3 <br /> Vature of Applicant-Title ate <br /> M.ICENTRALSERVICESICLERICALIPUBSV.WKIMASTER.PSIENCROACHMENTPERMITAPPLICATION.DOC (09/13) <br />