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F'i iP 1 :CAL I FORK I A WATER SEP)I CE FAQ: Ho. :2094640195 Jun. 1 41 F <br /> APPLICATION FOR ENCROACMENT PERMIT <br /> flr SASE PRINT: # Q <br /> osr3:cs 1US3 ONLY <br /> Date <br /> To'. couat ,70B a.L 1.------ RL <br /> o: San .'oaq,;„ Y CR <br /> Department of public Works ABN �-�-- <br /> EXP. DA's / <br /> vnn TO °-- nRsv$taaYs <br /> (Applicant Name) AEA <br /> \,CEO A.�L � 1C TYPE a� -- <br /> ��- (Mail ing Addxeas) FORMS -r- <br /> NOTE <br /> (City, State, .Zip Code) i <br /> (Asea Code T0j0Vhone dumber). <br /> Sketcb• (Detailed plaxs may be submitted) <br /> The undersigned hereby,applies for permission to.Oxcavate•, construct and/or <br /> othexvise-zucroach'on •CountyHighway 2tight-of�W3yt070. the b <br /> CD approximately lCk1 i � eet _ le <br /> of , ,. ' a. . Y e�forc► g th <br /> 01X g rk (aes ription of.work) : c .' allow m(A <br /> Work will c:o=neace on or'about I g.,n tofor approximately <br /> (nom "3ays• ' <br /> I, the und4rsigaed certify, that I am the ovnex' of,the respective-property, or am <br /> qua.3.ified'to represesnt the owner and •ajree to do the work described above in , <br /> accordance with the rules, re ti.` of Sao Joaqu�. Cdunty and subject to <br /> inspection and approval.. ���� [ '•4� <br /> Signnture of Applicant - i.tle Da e <br />