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APPLICATION FOR ENCROACMMNT PRRXST <br /> ��EASB._PRINT: . <br /> Date ( : oyria ash 0gLy <br /> To: San Coaqu.in Comity JCB # 21LL 'Z RAF # <br /> Departmezzt of publics Works APM -- _-- - Cit "# <br /> 1 / <br /> R". "ATE <br /> V VALID S 2 To <br /> (Applicknh MNW) S=T Alp..430 Q, AREA ,r <br /> ss/u� <br /> (Mailing Addraoe) FORMS. <br /> (City, 96nte, .zip coda) <br /> .(,Axaft Code - TelsVhome NUMber) <br /> Sketch (Detailed plane may be submitted) <br /> The uilde�t` igried hereby applies for perblission to:excavate, 'construct and/ox . <br /> — - - - - <br /> otherwipe­eacroacon:•Cp ty•Hig1b?pay Ft.,:ight-af_w4L ­Oa-the �' <br /> d'_ c approximately fee mile <br /> of <br /> ,'hy'pex fo ircg.the <br /> lbl2owin work (C`Leecription of. work) : C Vl-r to •t iec:Q <br /> Work -ill =or.=qe-'aC_ or,. or aboac + for approximately <br /> 4 days <br /> I, the underbigned certify that I am the owner. of• the respective -,property, or am <br /> qualified to represott•the owner and agree to- do the work descrilJed above in <br /> accordance with the rules, regalatiane 'of San aoaqu,,im County and subj eat to <br /> inspection and approval. <br /> si911at=e of Applicant - Title 1; <br /> �� 1�3 ; <br />