Laserfiche WebLink
APPLICATION FOR ENCROACHMENT PERMIT <br /> PLEASE PRINT: <br /> Date 1 -9 — 2 el!57 OFFICE USE ONLY <br /> To: San Joaquin County JOB# 7y c., REF# <br /> Department of Public Works APN _ CR# <br /> EXP.DATE <br /> �y S ( <br /> 7 '1 11 S6 l D 3 VALID Tb DRIVEWAYS: <br /> (Applicant Name) STREET uet1�. <br /> q0 AREA i�� r QUAD t4F <br /> — ���� � TYPE t. E' (. AttQww'Ac ;r <br /> (Mailing Address) FORMS Ss rww 2 rcc� r.�`!, • �, <br /> NOTES <br /> (City,State, Zip Code) <br /> (Area Code-Telephone Number) <br /> Sketch (Detailed plans may be submitted) <br /> The undersigned hereby applies for permission to excavate,construct and/or otherwise encroach on County Highw y Right-of-Wjay on <br /> the Ly side of S r e( approximately G(!.� ee ile <br /> of—r �--5 - by performing the following work(description of work): <br /> Work will commence on or about_ ��.-® .w � �,����__for approximately,____��� 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 /> Signature of Applicant-Title Date <br /> M11lCENIRALSERVICESICLERICALIPU&SV.WKIN,ASIERPSIENCROACHMEIJTPEP,M17ITAPPLICATIONNOC (09m) <br />