Laserfiche WebLink
APPLICATION FOR ENCROACHMENT PERMIT <br />PLEASE PRINT: <br />Date OFFICE USE ONLY <br />To: San Joaquin County JOB# 790690 REF# <br />Department of Public Works APN CR# <br />EXP. DATE I R,, <br />QPi4 "M00 Gr:,("_P4'Nlol,VALID It IS 0 DRIVEWAYS: <br />Applicant Name) STREET <br />AREA I QUAD <br />TYPE r <br />Mailing Address) FORMS o <br />NOTEStrsa-4a 1"AC) <br />City, State,Zip Code) <br />559} G.'s i — t3.-•ca <br />Area Code-Telephone Number) <br />Sketch (Detailed plans may be submitted) <br />56-- A-r•Tp-G,b-s%ri <br />The undersigned hereby applies for permission to excavate, construct and/or otherwise encroach on County Highway Right-of-Way onthesideofapproximatelyfeet/mileofbyperformingthefollowir (description of work): <br />Gfi Irt! /L /6 t'C C OSS C D!? Lr? <br />CL/Arlon r l,14 y'!4* <br />1 <br />le. <br />Work will commence on or about Nav tmot S for approximately.3u days. <br />I, the undersigned, certify that I am the owner of the respective property,or am qualified to represent the owner and agree to do theworkdescribedaboveinaccordancewiththerulesandregulationsofSanJoaquinCountyandsubjecttoinspectionandapproval. <br />D ip <br />iiii0` <br />fop- '-tNC <br />Signature f`' cant-T tle Ilra Date <br />E:NUB-SV.WKIAIASTER.PSIENCROACHMENT PERMITAPPLICATION.DOC (01/08) r(5f5f) / Yr t't