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APPLICATION FOR 1ENCROACM&WT PERMIT <br /> Date } orlrxcz USE ONLY <br /> TO: SWX c'.oaquin County JOB . 13-00177 RLS <br /> Department of Public Works AP9 CR <br /> VAzrID• '110 It, 1; to bRx74dA'3'3 <br /> ° tAPP33cant ��mo) SZ�2EE`T uC.t.r�y AJE. _� <br /> t C)A. AnEA ivc_rraPJ Qt= Nt <br /> 'I^?SMaLilin __ t <br /> S FORMS <br /> NOTE <br /> (city,"State, -Zip Code) <br /> Com ! <br /> (Area Code - Teleephone Neer) <br /> Sketch (Detailed pia= may be Submitted) <br /> I Aa 6•42d f <br /> The = ersigned bereby app3,ies for permission to.exaavata, cast ictIand/or <br /> otherwise- acroach•on -County..Highway Right-of-Wa ••oa•the <br /> approximately o S fee /Mile <br /> of • • , by'pexfoxmizig the <br /> following Wvx)c (description of.-Work) : <br /> F"C, Lk S <br /> Work will commence on or'about tor approximately <br /> days• , <br /> T, the undersigned certify, that azn the owner' of•thexespective .property, or am <br /> qualified to represent the owner and agree to do the work described above in , <br /> accordance with the ralles, r 17 ioz)s San Joaciu�n County anal sublect to <br /> inspection and aoprovw . <br /> Signature of AppS3.aaat - Title <br /> F=M.rsVZaS= (6100) ' <br /> • . t <br />