Laserfiche WebLink
APPLICATION FOR ENCROACHMENT PERMIT <br /> PLEASE PRINT: //� <br /> Date L' 'd�G7 OFFICE USE ONLY <br /> To: San Joaquin County JOBREF 4-- <br /> Department <br /> _Department of Public Works PSN CR n <br /> EXP. DAT C oGo <br /> rC7 1(✓ VALID 3 1 0 TO t.11rdoe, DRIVEWAYS: <br /> (Applicant Name) STREET 9- Doe. <br /> /( ' / / AREA -WogGY Qom . — — <br /> `-1 oq o �1S!` (�. TYPE /'46 * _ <br /> (Mailing Address) FORMS 6lJiW� 'e <br /> NOTE _ <br /> __ ST�.KTC� � C}l 95204 <br /> (City„ State, Zip Code) _ <br /> 209- q42.- r(of e> _ <br /> (Area Code - Telephone Number) <br /> I <br /> Sketch (Detailed plans may be submitted) <br /> SIL <br /> �W <br /> 51DE.WAIK <br /> 4-75' -' <br /> E%cmpmr- G1 4'x 4' Silltla z- <br /> a <br /> MACWrAVQ VZ. <br /> Q <br /> The undersigned hereby applies for permission to excavate, construct and/or <br /> otherwise encroach on County Highway Right-of-Way on the E side of <br /> MAC A2Sl�' X bg approximately Aex: { <br /> PP Y 4 feet mile <br /> of AdlAk- by performing the <br /> following work (description of work): EX(1� j-- --��X'4 ,_� y, <br /> I <br /> Work will commence on or about 3 l Dom_ for approximately <br /> 9U days <br /> I, the undersigned certify that I am the owner of the respective property, or am <br /> qualified to represent the owner and agree to do the work described above in <br /> accordance with the rules, regulations of San Joaquin County and subject to <br /> inspection and approval. <br /> Siguatu a of :,-T--cart - Title Date <br /> MASTEB.PS',FEESC-ML (610U) RETURN PERMITS TO: <br /> PG&E <br /> JOB PROCESSING DESK -BLD 1 <br /> 4040 WEST LANE <br /> rTnhILTl1 A! r`A Qr+7nA <br />