Laserfiche WebLink
APPLICATION FOR ENCROACHMENT PERMIT <br /> PLEASE PRINT-// �--++ <br /> Date � � DCO" �OO'l n OFFICE USE ONLY <br /> To. San Joaquin County JOB # REF # <br /> Department of Public Works 44 PIN CR <br /> ,,����// //��, /� <br /> EXP. DATE lal- <br /> R6, `!` /f�/f Ji lY/S VALID 1-1-00 TO DRIVEWAYS: <br /> (Applicant Name) STREET 25Q!'M /✓F <br /> }-RFA stac.(-ru,/ guAD A16 _ <br /> TYPE zLL flgLE <br /> (Mailing Address)S7/� FORMS/ SGL/ NOTE <br /> (City, State, Zip Code) <br /> (209) �;7'Va <br /> (Area Code - Telephone Number) <br /> Sketch (Detailed plans may be submitted) <br /> A1141 <br /> I <br /> The undersigned hereby applies for permission to excavate, construct and/or <br /> otherwise encroach on County Highway Right-o£-Way on the SO UTA%' side of <br /> BRl�iSl/Il �%Gz approximately 7 ee /mile 610 <br /> of f 15 ZVC -7 CAI by performing the <br /> _ <br /> following work (description of work): <br /> VIZE4X 4'X 4' �rGGf/OLra �� .�.slYF�Y/ st/7` <br /> 212 E '� /i4/17�Tc�/' — Lc t/6 771 AF S4 ' 70 EASE` <br /> Work will commence on or about ,,7-✓Q(„ for approximately <br /> 9� 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 /> Sig—t a Of Applicant - T-4 tla Date <br /> MASTER PS',.FEESC::L ,;,00, RETURN PERMITS TO: <br /> PG&E <br /> JOB PROCESSING DESK -BLD 1 <br /> 4040 WEST LANE <br />