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FROM :CALIFORNIA WATER SERVICE FAX NO. :2094640195 Nov. 06 2009 02:45PM P 2 <br /> APPLXC,&TION FOR MCROACMMT PERMIT <br /> zrjimg PRINT: <br /> Date �l�l �,1.J.� OFF=C8 VS8 mmy <br /> TO: Saxe Joaquin County JOB � �,�DO�Z Rnp # <br /> Department of Public Works APX CIS # <br /> W. DATE <br /> VAL=> �Q •. DRtV8f0A,Y3: <br /> (A+plicnnt Name) 87?MT <br /> A QMUD <br /> TYPE Z ' <br /> (Nailing AAdr;mvo) FORMS <br /> HOTB <br /> • (Citxr, St+ata, .Zip Code) <br /> (Area Code - Telephone X=g;,or)• . . <br /> Sketch (Detailed ilans may be sb&�itted) <br /> The =derslgned hereby.applies for peratiss;,on to.excavate►, construct and/or <br /> otherwise•-encroach•on 1Cb%=tY•Highway Tri h <br /> g t-of-way��t.at�a f�the <br /> approxitmtelY <br /> , a , by'�aeY€ormizigg the <br /> -'0110wing work (rlescriPtion of,work) s �. <br /> ' 0 <br /> TV 15� <br /> ISM 3 <br /> Work will a0 Q <br /> mmence Qa or'about for approximatel' <br /> Q days., <br /> 1, the undersigned certify tbat i am the owner' of.the respective, property, or am <br /> qualified to represent the Omer arid'a�ree to do the work described above in <br /> accordance with the rues, regulations'of San tT0ac ,`Cpvnty and stab j ect to <br /> inspection and approval. 1-U5•(p', ' <br /> Sig,aatUre Of lIcant <br /> e Date <br /> rc�+raR.pllrasc�a ra/oos .., , <br /> s <br />