Laserfiche WebLink
APPLICATION FOR ENCROACHMENT PERMIT <br /> PLEASE PRINT: <br /> Date OFFICE USE ONLY <br /> To: San Joaquin County JOB # �t�-�P REF # <br /> Department of Public Works APN CR # <br /> EXP. - DATE <br /> Cr VALID 3 TO �f lDRIVEWAYS: <br /> (Applicant Name) STREET (AMW46Z L <br /> AREA uN QUAD F5 <br /> 4o o ay--5T 69w TYPE !E <br /> (Mailing Address) w FORMS Lt UV -�� <br /> 6i- C6 n , 6& �Cf* NOTE <br /> (City, State, Zip Code) <br /> (Area Code - Telephone Number) <br /> Sketch (Detailed plans may be submitted) <br /> 1019 ?>104A- <br /> The <br /> >1z The undersigned hereby applies for permission to excavate, onstruct and/or <br /> o herwise encroach on County Highway Right-of-Wayslon the side of` <br /> LA approximately feet/rwOre 004h <br /> of by performing the <br /> followin work (description of ork) : <br /> Work will commence on or about G2 for approximately <br /> l(0-)v 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 /> _ c <br /> Siature of Applicant - Title Date <br /> MAST .P \FEES=L (6/00) FETURN PE'"Q�'� ■O• <br /> • � Q, ^ <br /> 4040'WOM Lar* y <br />