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FP IM :i-AL I FORK!I A I,,IATEP SEPI,:'I=:E FAX NO. :2094640195 J_i I. 21 200E 02:32PM P b <br /> A PL16_&Txox Fox, ENCROACMa= PERMIT <br /> pLEASI PRINT: "''� <br /> t - <br /> Date 1�,�-� tl� I- J4�rS OFFICE uS9 ONLY <br /> To: Saxe Joaquin County Top $ ,�C'77 REF t - <br /> Department of public Works "X CR: � <br /> VAL M X7-,4- TO <br /> (Applicant (Name) STREET <br /> APEA <br /> TYPE : <br /> (Mailing Address) oizrrs r� ` <br /> NOTE • <br /> (city, 1St ata,,�zipo code) <br /> (Area Code - Telephone Ntnber) <br /> Sketch (Detailed pla= may be submitted) <br /> The undersigned bereby,applies for permission to.excavate, construct and/or <br /> otherwise-encroach•On 420=ty•Eighw'ay Right-tai-Way aid the MTQZt t' - <br /> t��FZN`�a"E.._Y A� approximately _- -- a m'�1.� 'G-..� <br /> Of CVS SEN, <br /> , '• ' fox'ming the <br /> following work (description of,work) : <br /> Z_4l l X T <br /> work will commence on or'about for approximately <br /> 4aQ days. pproximately <br /> 1, the underaigned certify, that S am the owner of,the respec'tiv'e -Property, or a.m <br /> qualified to represent the owner and- <br /> accordance to do the work described above in <br /> accordance with size rule , xe9ulations'of Sam Jonq ?n c6uaCy and s <br /> inspection and approves, ubs act to <br /> � <br /> SigzYature of Applicant Title Date <br /> rusxa�t,ys�r�ssc� tc�co� -• , <br /> • titi <br />