Laserfiche WebLink
APPLICATION FOR ENCROACHMENT PERMIT <br /> PLEASE PRINT: <br /> Date 04-08-2015 OFFICE USE ONLY <br /> To: San Joaquin County JOB# REF# <br /> Department of Public Works APN CR# <br /> EXP.DATE j - 15 <br /> Nhan Ly VALID TO ( - DRIVEWAYS: <br /> (Applicant Name) STREET <br /> AREA u QUAD _ <br /> 850 Stillwater TYPE , <br /> (Mailing Address) FORMS <br /> NOTES <br /> West Sacramento, CA 95605 <br /> (City,State, AZip Code) <br /> 925-327-0990 /V Q-30 �>G-&, vq <br /> (Area Code-Telephone Number) <br /> Sketch (Detailed plans may be submitted) <br /> Construction drawing is appended. Please refer to attachment. <br /> M 431 I iC 1 tLO <br /> The undersigned hereby applies for permission to excavate,construct and/or otherwise encroach on County Highway Right-of-Way on <br /> the West side of E. Funck Rd. approximately 300' feet/mile South <br /> of North Duck Creek , by performing the following work(description of work): <br /> Replacement of deteriorated electric(facility)wood pole. <br /> Work will commence on or about 7-10-2015 for approximately 30 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 /> c�hwr�?p - Estimating Engineer 04-08-2015 <br /> Signature of Applicant-Title Date <br /> M:ICENTRALSERVICES4CLERICALTUB-SV.MMASTER.PSIENCROACHMENT PERMIT APPLICATION.DOC (04113) <br />