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APPLICATION FOR ENCROACHMENT PERMIT <br /> PLEASE PRINT: <br /> Date <br /> V <br /> L; r- <br /> Worxsi A; N <br /> _XDA'7- <br /> VAJD ;''RIVEWAYS: <br /> (Applicant Name) <br /> -STREET <br /> AREA. <br /> AD <br /> Wailing Address) FORM'S <br /> fcify,State, Code) <br /> _4 — <br /> (Area Code-Telephone Number) <br /> Sketcr(De:taije�ours <br /> 4� O.N <br /> he undersigned i,,ereoy applips for <br /> oermission to excavate, constrUct andicF otherwise en,-roa-h cn Counity Hju�,way <br /> pit A 0 im i e at 4 SAQ-Oi �e,- I � 1. 1 "'ght-of-Wav on <br /> apprcxjrrai.Jiv 5-C, <br /> iie Ocu <br /> Of- v 4w` w ce <br /> by performing the"allowing work(des&ID,ion of work`: <br /> ,n o, aboU4 3 <br /> K, aaY& <br /> the uncersigrec,certify�p'at am the owne,- 04, the respective property. or a, ,7,j al;fied w preSe.r,'the owner <br /> 'A'Cirk described above ir,a -4.ee to do the <br /> accordance With the and reguiations of Sar.Joaquin 0-c-u ,tai and subJeOt f and approvai. <br /> Signat f <br /> 1) <br /> f Applicaricar�t­_— <br /> Title <br /> tate <br />