Laserfiche WebLink
APPLICATION FOR ENCROACHMENT PERMIT <br /> PLEASE PRINT: <br /> Date ' z-y �J` OFFICE USE ONLY <br /> To: San Joaquin County JOB# REF# <br /> Department of Public Works APN CR# <br /> EXP.DATE i /S` _VALID l5 t 0 / !S DRIVEWAYS: <br /> (Applicant Name) STREET At-:gY rW- <br /> 2 AREA f,P�Gy QUAD � <br /> -Z3 �_ O� TYPE C4'03"'P-6 <br /> (Mailing Address) FORMS .-.- <br /> ,.� p NOTES�•�`-fir 1.46 / ,j 27 � 1 vqy �rti7 Crr�g.�� a+J r Ih <br /> (City,State,Ziip�Code) to,z r 9 Ani To 3:to R <br /> (Area Code-Telephone Number) <br /> Sketch(Detailed plans may be submitted) <br /> 33 <br /> The undersigned hereby applies for permission to excavate,construct and/or otherwise encroach on County Highway Right-of-Way on <br /> the side of approximately feet/mile <br /> of by performing the following work(description of work): <br /> Work will commence on or about 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 abov in accord ce with the rules and regulations of San Joaquin County and subject to inspection and approval. <br /> Signature of Applicant-Title Date <br /> EIPUB-SV.WKVM8IERPSENCROACHMENTPERMITAPPLICATION.DOC (01108) <br />