Laserfiche WebLink
APPLICATION FOR ENCROACHMENT PERMIT <br /> PLEASE PRINT: <br /> Date ��q 1 S OFFICE USE ONLY <br /> To: San Joaquin County JOB# 7005'2- REF# <br /> Department of Public Works APN CR# <br /> ,�^ ` EXP.DATE -2-- l - 16 <br /> I"IOVF'S-rA �J AC-IRUE7 VALID 1,0-(-(5 TO DRIVEWAYS: <br /> (Applicant Name) STREET 5otyG T <br /> AREA Ie)4- QUAD <br /> 612.1 '0LL 114XF;12 AI CAyaJ 0 7_14n TYPE &tie <br /> (Mailing Address) FORMS S,� WW Rzq <br /> NOTES <br /> S a,4 2Amw CA 94-51b3 <br /> (City, State,Zip Code) <br /> 925- Zqy- 3813 <br /> (Area Code-Telephone Number) <br /> Sketch (Detailed plans may be submitted) <br /> S E e l-�-r r�4eN►nN-rS <br /> The undersigned hereby applies for permission to excavate,construct and/or otherwise encroach on County Highway Right-of-Way on <br /> the side ofy A 2.,Ldu S L-zxcA-x tor43 approximately feet/mile <br /> of , by performing the following work(description of work): <br /> lnJS�-�orLt_ 3 1MIL65 OF NEW 2.4";nc-�-% 2[aA1J5misslow Q14E ALONCa <br /> VP�Q- Te.tacics. <br /> 'PCE PtV1 � 3otflp�y3o I . <br /> r&)CR-04 MEnfTS tNC-LubE 1-U-4-AVA71oN Atko �P.��w C�'I�S�L- �' ALL <br /> ft Her- Pozytqs /.dGU;,D)NG cAL'-TZAtjs k/ILL Of 9Vi pD FL..4. !6'T-�P�`-y <br /> Work will commence on or about ';F - L 2015 for approximately FESRuA9-1 ZOV6 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 /> P p-MCct Hc! 7-- 3/1`t 1 1S <br /> S!pKatuV6 of A6plicant-Title Date <br /> IAICENTRALSERVICESICLERICALIPLJB-SVVJKIMASTER.PSIENCROACHMENT PERMIT APPLICATION.DOC (09113) <br />