Laserfiche WebLink
APPLICATION FOR ENCROACHMENT PERMIT <br /> PLEASE PRINT: <br /> Date OPTICS USE ONLY <br /> To: San Joaquin County JOB # U�°2' '6 RBF # <br /> Department of Public Works APN CR # <br /> rr EXP. DATE - - <br /> 07t <br /> v VALID / TO DRIVEWAYS: <br /> (Applicant Name) STREET N/cD,eCrR IAA1 i <br /> AREA STd[A-rbt/ QUAD <br /> TYPE Zol;�q <br /> (Mailing Address) FORMS ,5 �u�r�J A-40Y <br /> NOTE <br /> (City, State, Zip Code) <br /> (Area Code - Telephone Number) _ <br /> C3 th <br /> Sketch (Detailed plans may be submitted) <br /> TRAFFIC CONTROL PLEW <br /> SHALL BE AS PER-r c -;,rn <br /> CURRENT M.U.T.C.L5� o Do <br /> CALIFORNIA SUP9EMENT�E:Z <br /> Q <br /> _ o � <br /> �K c <br /> 3/4 8� <br /> The undersigned hereby applies for permission to.excavate, construct and/or <br /> otherwise-encr a--ch on-County-Highway Right-of-Way on-the A- side.:of <br /> approximately fee /mi6! Alb&=� <br /> of fel `� ! rV. Tac�C6 , by per€orming the <br /> following work (des ription of work) ,Wf- .BPS//4v t'. .b,A'/'.�2 .9 <br /> l j iSPS ¢� <br /> Work will commence on or about for approximately <br /> days. <br /> I, the undersigned certify that I am the owner of. the re spective, 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 /> Signature of Applicant Title ate <br /> KL9=.P9%F=®L (6/00) <br /> 1, <br />