Laserfiche WebLink
APPLICATION FOR ENCROACHMENT PERMIT <br /> PLEASE PRINT: <br /> Date / a t'8 j OFFICE USE ONLY <br /> To: San Joaquin County JOB# /,fjj REF# <br /> Department of Public Works APN CR# <br /> EXP.DATE —Vd <br /> VALID h 13•rig TO 45" f -e>'7— DRIVEWAYS: <br /> (Applicant Name) STREET <br /> AREA %?Zpp�►4 QUAD A1141 <br /> TYPE -1P, Pers CLoSU�?i ' <br /> (Mailing Address) FORMS <br /> NOTES <br /> �%)G'k'rY Kuru t'ta <br /> (City,State,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 Highway Right-of_-Way on <br /> the side of 2RmEn/f� ,�(yllF approximately 6 Ei-u,,r=EfV fee** <br /> ��ry<i IYEl r , by performing the fo�win work(description of <br /> ' g ( ptron work): <br /> �Nn+i�r� t �'t��v l/Ffti �t <br /> L t, hr�n� <br /> Work will commence on or about S- ?-C; for approximately r f a , ,t. da <br /> I,the undersigned,certify that I am the owner of the respective properly,or am qualified to represent the owner and agree to do the <br /> worts described above in accordance with the noes and regulations of San Joaquin County and subject to inspection and approval. <br /> Signature of Applicant-Title Date <br /> E.WL SV.WIWSTENAS NCROpOp�PEMUMPLMAIIONDOC RM) <br />