Laserfiche WebLink
APPLICATION FOR ENCROACHMENT PERMIT <br /> PLEASE PRINT: <br /> Date 0 — 1 -g — OFFICE USE ONLY <br /> To: San Joaquin County JOB# J.3605z'Ga REF# _ <br /> Department of Public Works APN CR# <br /> ® EXP.DATE it p <br /> VALID !g (1,, 15 TO 1( 1 ,5' _ DRIVEWAYS: <br /> (Applicant Name) STREET <br /> AREA f\ QUAD & <br /> TYPE <br /> (Mailing Address) NFORMS <br /> OTES � � "� �hai <br /> (City,State, Zip Code) <br /> 1 -79'7 <br /> (Area Code-Telephone Number) <br /> SI<etch(Detailed plans may be submitted) <br /> The undersigned hereby applies for permission to excavate,construct and/or otherwise encroacb on County Highwa Right-of-Way on <br /> the_ side of i D l',,h tr-an approximately e Wile <br /> of '4 � �� by performing the following work(description of work): <br /> Work will commence on or about for approximately y n'n 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 /> ek <br /> Signature of Applicant-Title Date <br /> V ICENTRALSERVICE&Ct ERICALIPUB-SVWKWASTER PSIENCROACHMENT PERMIT APPLICATION.DOC (09/13) <br />