Laserfiche WebLink
APPLICATION FOR ENCROACHMENT PERMIT <br /> PLEASE PRINT: <br /> Date 0 ® I -3 " 2-01!;— OFFICE USE ONLY <br /> To: San Joaquin County JOB# 7�005 Z.4. REF# <br /> Department of Public Works APN _ CR# <br /> Q EXP.DATE /® /5- <br /> 1 �iy1 3 16 2 D J VALID /-o �,�fS—'� TO /o ig1 DRIVEWAYS: <br /> (Applicant Name) STREETr Ave w <br /> 11qL9 AREA qac,( , QUAD "5��� "a jj e TYPE h A**V Q-,o <br /> (Mailing Address) FORMS WAAd, Zj �, ,, 6W, <br /> NOTES 00 <br /> C A q�� <br /> (City, State,Zip Code) <br /> 31 1; — 1 "7 rS 7 <br /> (Area Code-Telephone Number) <br /> Sketch(Detailed plans may be submitted) <br /> The undersi ned hereby applies for permission to excavate,construct and/or otherwise encroach on County Highway Right-of-Way on <br /> the side of C a approximately 3� .fe'emile S <br /> of — uacc s �'na-I- by performing the following work(description of work): <br /> Work will commence on or about 1,!g— approximately 9 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 /> MICENTRALSERMCESICLERICALIPUMVWKWASTER.PSIENCROACHMENTPERMITAPPLICATION.COC(09M) <br />