Laserfiche WebLink
APPLICATION FOR ENCROACHMENT PERMIT <br /> PLEASE PRINT <br /> Date QG7 OFFICE USE ONLY <br /> JOB # //GYM S <br /> To: San Joaquin County REF #CR # <br /> Department of Public Works APN <br /> nl EXP. DATE <br /> L , [c �� 6o�d2�0r- VALID TO DRIVEWAYS: <br /> (Applicant Name) <br /> STREET v �CS <br /> Q / �T 4 L� v AREA `A�`TA QUAD _6L,-) <br /> TYPE `bo E * <br /> (Mailing Address) FORMS ILA) <br /> RA�Co Stc'&ZW 9 S 3�� NOTE <br /> (City, State, Zip Code) <br /> 6 - 3 '7 <br /> (Area Code - Telephone Number) . <br /> Sketch (Detailed plans maybe submitted e..X T1F11J S/owl Or o►'S �//� <br /> /�a cQ 740 CO M A' <br /> a Ca <br /> C✓i c v) 5 LV frA Ge D t,.anG_r S (0' v�d� Y1 U t ►v� Cd v�77 <br /> The undersigned hereby applies for permission to .excavate, .cons ruct and/or <br /> otherwise-encroacl 7 o County Highway Right-of=Ways on t� 6 -side.of <br /> t^fS Qo approximately feet/mile <br /> of by performing the <br /> following work (description of,work) : rbc ore <br /> ------------ <br /> Work will commence on or about 0 . for approximately <br /> b n day*. <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 /> Sign to o plicant Title Date <br /> MASTSR.FS\P=S®L (6100) `� <br />