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7F=ih1 :r=HLIFCiF9 IH i:;H`�F' '=ERt;I.:E FAX NO. :2C194r4019F_ Tul. L 1f=r2:7 Ft1 F <br /> APPLICAT109 FOR JENcRoAcE2aM p R x <br /> PLEASE PRINT: <br /> nate aFFacs USE ONLY <br /> To: Ban Joaquin Couxxty aOB #_V4VREF # <br /> Department of public works ,t�Z� CR � <br /> EXP. <br /> DATE <br /> (Applicant xa=e) STRLE9.`\rN <br /> w <br /> AREA QUAD <br /> TYPE—4 e,Wailing Add:voau) FOM <br /> - W <br /> .NOTE � <br /> (City, `Sbate, .Zip Coda) <br /> (Asea Code - Telephone Number) <br /> Sketch (Detailed plans may be submitted) <br /> The =dersigned hereby applies for permission to•excavate, construct and/or <br /> otherwise-encroach On Cautxty 8a shway Right-of-W&y+-oa•the 14�A-wo4 side <br /> off, .�IT'�tZ !'.1N4-'fA _gpYS proximately "- __. feet/feet/mile of <br /> fallowin Y+tork by'perfoxmizig the <br /> 9 (clescriptian af;work) <br /> ^\IRLV S <br /> Work wi3 commence am or'about „pb-IlotOdD <br /> �Q <br /> days for appro imately <br /> -' <br /> 1, the undersigned certify. �.t Y am the owner'' of,the xespecti�re propert or am <br /> qualified to represent the awxzer anda9?ee t0 do the y' <br /> accordance with the ruI s, x work described above in <br /> 'of San Joa•c42n County and subject to <br /> a-sMspection and approval esula.t.i.ons <br /> Signature of Applicant Title <br /> Date <br /> rsAcx�.yr\rsacc,a, lc/oo� - . <br />