Laserfiche WebLink
APPLICATION FOR ENCROACHMENT PERMIT <br /> PLEASE PRINT: <br /> Date OFFICE USE ONLY <br /> To: San Joaquin County JOB# REF# <br /> Department of Public Works APN CR# <br /> 7 EXP. DATE =6�:r - <br /> VALID -� 'Tb `--/ 2p DRIVEWAYS: <br /> (Applicant Name) STREET - <br /> AREA QUAD S <br /> TYPE lceyy ,CV, <br /> (Mailing Address) FORMS SS�,,� <br /> NOTES <br /> (cJfy,State,Zip Code) <br /> (Area Code-Telephone Number <br /> Sketch (Detailed plans may be submitted) �- <br /> The un ersigned hereby applies for permission to excava e,con uct and/or otherwise encroach on County Highw Right-of-Way on <br /> the side of �� approximately - feet/ ile <br /> of by performing the following work escription of work): <br /> lak <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 above in accordance with the rules and regulations of Sari Joaquin County and subject to inspection and approval. <br /> Signature of Applicant-Title Date <br /> M9CENTRALSERVICEMCLERICALTUB-SV.WKMASTER.PSIENCROACHMENTPERMfTAPPLICATION.DOC (09113) <br />