Laserfiche WebLink
APPlICAT!ONI"OR ENCROACHMENT PERMIT <br />PLEASE PRINT: <br />Date 06.0\\Pv'\M~dO dOllJi' <br />To:San Joaquin County~) <br />Department of PublicWorks <br />CALI F-D«(()i A WATEI?.0E(llJ)~E. <br />..(Applicant Name) <br />'(PaC).E:,I-...AF-fj'/EnE ST' <br />(Mailing Aqdress) <br />-,sTOC'.-lC-TbN 01 CfSd-DS <br />(City,State,Zip Code) <br />';){Jg\Lj 10 lj -'2;,3 J l~,__ <br />~7(Area Code 0 Telephone Number) <br />Sketch (Detailed plans may besubmitted) <br />OFFICE USE ONLY <br />JOB#77fJ072 REFit <br />APN CR# <br />EXP.DATE 7-'-lb,VALID 3-2.{-tb TO 7-/-f{:>DRIVEWAYS: <br />STREET tI1l/"lIl(/"Tf'illhU21.,,,• <br />AREA £f-aek:fon Q AD 'C (- <br />TYPE "~' <br />• <br />FORMS .'ii llLft )peCl«(NOTES <br />-,-,..-.. <br />. <br />The undersigned hereby applies for permission to I'lxcavate,construct andror otherwise encroach,on County Higllway Right-at-Wayanthffsideof''approximately ~fee!fmile _ <br />of ',by performing lhe following work (desc'riptionof work): <br />Wod,will commence on or about,~Zap~oximatelY days.C 5'I If<;)I,the undersigned,certify thai Iam the owner of the respective property,or am q alifie,to represent the owner and agreeto do the' <br />work described above in accordance with the rules and regulations of San Joaquin County and subject to inspection and approval. <br />~(),tlQ Q lle A.- <br />,I nature of Applicant.Title <br />.M:\GENTRAl5ERVlCESlCl.ERICAl.'LPlJB-SV.WK\1AASlER.PSlENCROACHMENT?ERMrT !lPPIlCA110N.DOC lO~11SJ