Laserfiche WebLink
APPLICATION FOR ENCROACHMENT PERMIT <br /> PLEASE PRINT: <br /> Date 5 I OFFICE USE ONLY <br /> To: San Joaquin County JOB# 110()05- REF# <br /> Department of Public Works APN CR# <br /> EXP.DATE v3 <br /> ; <br /> D}tti L U Ntn►►f Fi(jt`L ()t5-t/t� cI VALID '3 15"~ T 37,-2,3 - DRIVEWAYS: <br /> (Applicant Name) STREET 4z.,&7r Lz v� ' 4 <br /> AREA /ac AD ` <br /> 012 j}r.+o'l– I2.s7. TYPE ' �x�-�",D,Pf VF'-- <br /> (Mailing <br /> JF-(Mailing Address) FORMS <br /> NOTES <br /> LoGK&Poitp ,t,,4' X1523 7 <br /> (City,State,lip Code) D rim �?l Sf1T1��1�r9 <br /> C2o� -�Z? - os-6 i-1 <br /> (Area Code-Telephone Number) <br /> Sketch(Detailed plans may be submitted) <br /> The un ers'gne hereby applies for permission to excavate,construct and/or otherwise encroach on County Highway Right-of-Way on <br /> the N l/ti� side of /4vv ti SlS` approximately u ! ! 0, feet/mile <br /> Of _,by performing the foli wing work(desc(ption of work): <br /> Cairech+�ti f,�,w,y�+.�wS^ fb ++'rhe Fra�r-+6zsurry2s Bias-) LN-2 r o-yit <br /> - <br /> Fi+ZF if i G/iT62S <br /> Will 13� GoriGh,nt Hyl%n a'tt.in S �ftaN1 _ r5ltoo)1}•r �� <br /> "'7J <br /> Work will commence on or about I for approximately N r 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 /> 'XV �� — 5- 1!�— <br /> Signature of Applicant-Title D to <br /> WCe47FM ERYCES1tMM%K8-SVWAVAkSTER nFJP:RO.ACWOa RERV�TPFPUCATIul DOC tY..40) <br />