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FROM :CALIFORNIA WATER SERUICE FAX NO. :2094640195 Oct. 21 2005 02:45PM P 2 <br /> APPLICATION FOR WCROACMOMT PERMIT <br /> PLEASE PRINT- <br /> Date '� " • OBD a oFFYcs VSR ONLY <br /> To: San Joaquin County JQB #—!3 0'7'7 REF � <br /> Department of Public Works A,pN C.R <br /> =V. DATE oq <br /> vALm to. To 1• t•09 mrrEti ys: <br /> iXpplicant Name) STREET _...�i�jut- A <br /> TYPE '(-t <br /> Mailing addrosII) � "— FORM <br /> NOTE ' <br /> • {C3�tgy, Starts, •xip colo) � . <br /> (Area Code - T'elespphoae ljumber), <br /> Sketci� (Detailed plazas may be si,16 cdtted) <br /> Ta undersigned hereby applies for permission to,excavato, construct axed/or <br /> otherwise-encroach•on 'County•Highway R 9ht--0f-way1•40jj.the .\ s'ide:_hf <br /> ^ <br /> approximately ca 4� /Tine m oym-m <br /> e <br /> `' + , <br /> following work (description of;work) : by perfornd'nS the w, <br /> work will commence on or'a,bout VS •• w for approacxtnately <br /> ___�r K4 days. , <br /> X, the widersigned certify' that I am the owner' of, the respective 'property, or am <br /> qualified to represent the owner an& agree to do the work described above in <br /> aecor&-mce with the rules, regulations'of San Joaqu�n County and subject to <br /> inspection and approval,�tZ,-:C1.-;4Sa., <br /> Title Date <br /> m18r�r.?s�lacoIDL woo) <br /> . lF <br />