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FROM :CALIFORNIA WATER SE=RVICE FAX NO. :2094640195 Jun. 15 2009 11:31AM P 2 <br /> APPLICA` ION FOR BUCRQAG'M,[ENT PERMIT <br /> Rate OPPICE USE ONLY <br /> To.- San 47oaquin Co=ty JOS # "73©0?? REF # <br /> Department of Public Works APX clt � <br /> . DATE J1.VAz , <br /> . <br /> VALID- A:ls•o9 xo S. b-0? DRXV aAYS: <br /> {Applicaat name) s'x`PMT ,(u�,2aa«� A✓E. <br /> ARM - Q= <br /> TYPE �Y'046 <br /> ._ <br /> (mailing Addx�ass) Pom , /i✓�y� 'e-29 <br /> (city, state, .Zip Code) <br /> C RR - '_Mb X311 <br /> (Area code - Telep2e Amber), <br /> Sketch (Detailed �l.axs may be submitted) <br /> The undersigned hereby,applies for permission to.ex' te, construct and/or <br /> otherwise--encroach.n •County•Ri ghway Right-of-wayoCava <br /> ---- DUE, approximately sem_ £ mile <br /> ° A �.N� �+��1 � by perfoxmiAg the <br /> following <br /> oowing work <br /> (description of;work) : <br /> AMA <br /> Work will <br /> commence on ar'about A for approximately <br /> x, the =dersa,gned certify, that I am the owner of,the reIspective -property, or am <br /> qualified to represent the owner and agree to do tbe'wrork described above in <br /> accordance with the rule regulations,of san aoaqu�n County and vgbject to <br /> inspection and approval. <br /> Sigrnature of Applicant Title Date <br /> 1a►ea�t.v.Wnac:mm rcioo) <br /> t <br />