Laserfiche WebLink
APPLICATION FOR ENCROACHMENT PERMIT <br /> PLEASE PRINT: <br /> Date 0 — 1 .-3 — 2 d/, OFFICE USE ONLY <br /> To: San Joaquin County JOB# 17124-0sZ-41 REF# <br /> Department of Public Works APN CR# <br /> Q p EXP.DATE <br /> 1 � T Yh 6 2 a� VALID 9 T _ /I s' — DRIVEWAYS: <br /> (Applicant Name) STREET :7,W ,4 AVB. <br /> AREA -wekrs-3 QUAD E5 <br /> ® �!® �� TYPEa <br /> (Mailing Address) FORMS ,,jj, <br /> NOTES <br /> (City,State,Zip Code) <br /> 17767 <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 Highway Right-of-Way on <br /> the S side of_-.67 3 _3 1 4P0Lb,Q approximately 3 7 ee mile L.> <br /> of 7®r*_Ac-�� by performing the following work escription of work): <br /> Work will commence on or about ;9.-- ,�d b���- for approximatelyB > 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 /> M:ICENTRALSERMrESICLERICALIPU®-SVWKIMASTERPSIENCROACHMENTPERMITAPPLICATION.00C(09113) <br />