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DeOCT.18.200514-9:48AM APEX ENVIROTECH,INC., 209 ,t5U_L10_819 P.3 p ) <br /> APPLICATION FOR ENCROACMl = PERMIT <br /> Date �U�D OFFTCE tfS$ ONLY <br /> f <br /> To: San rTaaelu.in County r70B # IJrD _ REF # <br /> Department: of Public Works AEN CR 4 <br /> GG *, S u EXP. DATE - /� O <br /> P G Gt�l U W 4� 5 M - VALID 4�-/7.17 TO 77�� '__G s DRYVEWAT5 <br /> (Applicant Name) STREET 51AIM 5r w <br /> AR9A r4-Y QUAD � ' <br /> I y -N.Y' Wd- TYPE _Mo�►t ITo�tr1G1 Wim, <br /> - <br /> (wailing Addreea) FORMS W - Z9 <br /> I&Ncri CA ' !J�21010 NOTE <br /> (City, State, Zip Code) <br /> ^� (Asea Code - Te14p8ane 1,t mbar) <br /> Sketch (Detailed plans may be oubmitt;ed) <br /> f Gt-Li�� <br /> The undersign6d harelzy applies for pezma,srsiog to excavate, conar-ruccud/us <br /> otherwise encroach on County Highway Right.-of-Wax on the i �Sf sid of <br /> T $ OF 7�t approximately ©--_3�a f /mile V1171�. <br /> or - o ,mss Fs t __aAAJ7A- C_ by ptxroxmiizg the <br /> fallowing work (description of work) : <br /> 1 G <br /> r <br /> work will commence on or about _ ��L, fo:r appra=Lmatoly <br /> One, day*- <br /> 1, she Unaersiqued certify chat x am t7=e owadr vJC Lhe respecriva property, or am <br /> qualified to. represenc the owzier and agree to do the work described Above in <br /> accordance with the rules, re5ulations of Sari aeaquin County and subject to <br /> ±nspedtlon and approval,. <br /> =�8��_ <br /> Sti.gstatur f Rpplirant - Title Daae <br /> r�+�n..eA\PRAde��D6 ra/nor , <br />