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FPCIM :CALIFORNIA WATEF SERO I C:E FAX Nn. :2094640195 T_,1. �_ .`��4',� C13:10pM F' 6 <br /> APPLICATION FOR ENCROACEMNT PERMIT <br /> 2bgAgK PRII3T•- ^ <br /> Datel_ Ch1 � �'+�\i 1 Or?xC3 USE ONLY <br /> To: San LJOaquin County 470E g__i 3t 071 1 REF' <br /> hh' Department of )Public Works APN <br /> EXP. DATE 16. 1.01 <br /> L VALm• _714 TO 6• O DR V&i YS <br /> (Appxioant Name) STRM <br /> TYPE <br /> (Xzdliug Addross) FORMS 4.c�a <br /> NOTE <br /> (City S't?ata' .zip Code) <br /> (Area Code - TeXephone Number) <br /> Sketch (Detailed plans may be B-bbmitted) <br /> �� Q <br /> The undersigned hereby appUes for permission to,exc avat&, construct and/or <br /> otherwise-encroach,on County Rig y Itight_of-Why+•oA.the <br /> roxi <br /> of <br /> p�Ltin A` ....., a PP mately L106- f ag <br /> Poll by'performixtg the <br /> owing work (description of;work) : <br /> ' YAhL , r. ; <br /> Work will ao=ehceo -�--��—_ <br /> len s or'about <br /> days for approximately <br /> . ., <br /> I, the undersigned certify that Y am the owaexe of•the respective ,property. or a'm <br /> qualified to represent the owner and agree to do the Work described above im , <br /> accordance With the r4. e , regulati 'of Sari Joegtz <br /> inspection and approval, <br /> � Cows ty and subs ect to <br /> S2g'x),a�1r6 Of Z�C � •4��' "�Y�� <br /> �� ZLnt T�.tZ.6 <br /> Date <br />