Laserfiche WebLink
APPLICATION FOR ENCROACHMENT PERMIT <br /> PLEASE PRINT: <br /> Date OFFICE USE ONLY <br /> To: San Joaquin County JOB# 7 200 57 2- REF# <br /> Department of Public Works APN CR# <br /> EXP.DATE <br /> VALID 7-1-1 S TO DRIVEWAYS: <br /> (Applicant Name) STREET 5=IR±9�F <br /> AREA �_ Ql1AD _ <br /> 6�1 U ��esf L /y TYPE Ail 1hJ je <br /> (Mailing Address) FORMS S5 wlyV <br /> NOTES <br /> � ��V_ �14 q�zap <br /> (City,State,Zip Code) <br /> alb's- -;/ca-17("7 <br /> (Area Code-Telephone Number) <br /> Sketch (Detailed plans may be submitted) <br /> The ud�ersigned hereby applies for permis op,to excavate,construct and/or otherwise encroach on County Highway Right-of-Way on <br /> the ill PS r side of 1-�(u `( `1 approximately / Ssmile <br /> w� <br /> of-__ W i v1 , by performing the following work(description of work): <br /> b1 e 'k W, Stv�'_r <br /> Work will commence on or about -1- I S _for approximately fv days. <br /> I, the undersigned,certify that 1-2. owner of the respective property,or am qualified to represent the owner and agree to do the <br /> work described above in an m"towner <br /> the rules and regulations of San Joaquin County and subject to inspection and approval. <br /> Signature ate <br /> MICENTRALSERVICESICLERICALIPUMV.WKUMSTER.PSIENCROACHMENT PERMIT APPLICATION.DOC(09/13) <br />