Laserfiche WebLink
APPLICATION FOR ENCROACHMENT PERMIT <br /> PLEASE PRINT: <br /> Date ( � O w OFFICE USE ONLY <br /> To: San Joaquin County JOB # 430 SZ ` <o REF # <br /> Department of Public Works APN CR # <br /> EXP. DATE 1-71-07 <br /> �Ca GL VALID 0-12,,57L TO 1-31- DRIVEWAYS: <br /> (Applicant Name) STREET NosypN uoav <br /> AA^,;t _ AREA �ANTF�.A QUAD 5E <br /> 452�� W)&S-T, r� t' TYPE I%Lk-No(s- -I�Fi-scat <br /> (Mailing Address) FORMS SS/- &e K-VT <br /> NOTE <br /> ST�c cl 5204 <br /> (City, dtate, Zip Code) <br /> q4Z- 1537 <br /> (Area Code —Telephone Number)_ <br /> Sketch, (Detailed plans may be submitted) <br /> TRAFFIC CONTROL PLAN <br /> SHALL BE A5 PER <br /> CURRENT M.U.T.C.D. <br /> CALIFORNIA SUPPLEMENT <br /> The undersigned hereby applies for permission to.excavate, .cons•truct and/or <br /> otherwise-encroach on County -Highway Right-of-Way--on-the So%)3:3A side.:of <br /> ao��''pH QoAO approximately 20%4 feet/ WC-ST <br /> of M P 1 t-,s !!E R MRA r__C .` by -performing the <br /> following work (description of work) : MSTot-t- Pt_ C-;oS <br /> 01l ;e, l - y x�(' S E�1.�-10+-mss t �.f Ogg.;- , <br /> $"'VA 3053521 -7 <br /> Work will commence on or about MI c' J 0,NaU H 2CPr_> for approximately <br /> Z-3 <br /> 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 /> �l�,J Sct�rlt Ew"'fL"' <br /> �QS SSE-i 44rC- l�iS LV470� I Z <br /> Si ature of Applicant - Title Date <br /> MASTER.PS\FRES®L (6/00) -`� <br />