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��•'•� LG7 {Oi573L4 <br /> c i num iii vc <br /> ,APPLICATION .FOR ENCRO.A•CMM= pMzba-± <br /> PLFAO_PRINT: <br /> Date OFFICZ: USE ONLY <br /> - <br /> To: San JoagiLin County JOB # <br /> Department of Public Works APN CR <br /> B". DATE -/©' - { <br /> VALID' d n �U Dasa v alil. �. <br /> .(Applicant N ®) STAT <br /> /►z� //I�r1 1�rJ C <br /> AREA ftTAD �r <br /> — TYPE '— <br /> (Mailing Addreas) FORMS <br /> 'NOTE <br /> (City, 9tate, ,Zip Code) <br /> (Arem Code - lftmbes) <br /> Sketch, (Detailed plans may be shitted) <br /> File undevsigned hereby, applies £or. permission to .excavate, aons�ruct aur/nr <br /> otherwise-encroac)j•on..County..kIa ghway R5 go <br /> hti- f-i4aEy•vs -the <br /> .qi A►PsRT t�liF A(QR7M �+'L.=11�1 'of,.. . <br /> approximately _. OV61 R <br /> P�11 Q0� <br /> falXowi + ' by performing tha <br /> rig work (descriptzo:cL of; work) : gQAb C1ee..ir�'0e`��� <br /> No will commence on or,about Pte_ ' dot <br /> days. for approximately <br /> I, the ..underaigned atarti£y that I am the ,owner' of• the, respective+ •property, or am <br /> aalydanc to repxasent the owner and agzae' to do',the waxk described above in <br /> accordance with the rules, regu,latjons -of San Joaqui7e •Crusty and ed abot to <br /> ixispeetion and approval. <br /> S3 ature of App ant <br /> Atxe <br /> ' b e <br /> ' MI1G28tt.P9 <br /> � s <br />