Laserfiche WebLink
APPLICATION FOR ENCROACHMENT PERMIT <br /> PLEASE PRINT: <br /> Date OFFICE USE ONL'( <br /> To: San Joaquin County JOB# //ODDS REF <br /> Department of Public Works APN CR# <br /> EXP.DATE <br /> "A f VALID ,I ag TO !a 0 4 DRIVEWAYS: <br /> (Applicant Name) STREET <br /> AREA -S-racgM&I QUAD All <br /> vV TYPE Sti>6WAL K <br /> Mailing Address) FORMS Lam, Gra-c,r , cr- or <br /> ,. NOTES <br /> (City,State, Zip Code) <br /> 4 <br /> Jam" V / <br /> rea ode-Telephone Number) <br /> Sketch(Def q d plans ay be submitted) <br /> The undersigned hereby applies for permission to excavate,construct and/or otherwise encroach on County Highwa Right-of-Way on <br /> the ' side of Y-rrl � --f n e approximately /O e a ile <br /> of S" ,by performing the following work M6ription of work): <br /> Work will commence on or about 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 /> e19 YIA e 8 n . <br /> Signature of Applicant-Title Da e <br /> Y`,FORMS&TEMPUTESeNCRDACMMENT POW APPUCATrON.doc tom) <br />