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i Y ft <br /> MY <br /> APPLICATION ION P Olt.E CROACIiTNIE+N T PEI VII d <br /> rS+o <br /> s <br /> PLEASE PRINT: <br /> ' OFFICE USE ONLY <br /> Date JOB M i w-5 REFH <br /> { APN CRVM , <br /> To: San Joaquin County Highway Department. EXP. DATE (,-+s-cr7 <br /> ;. <br /> VALIDS- 0 7 TO G-15--u7 DRIVEVVAXS: <br /> ' AnyANCEC? GEOEVVVZPQNMEN-TAL 7JVC, g'1'IZEET <br /> ` , licant Name ; <br /> (Applicant• ) AREA STucic-ru� QUAD Cx', <br /> , 637 :SHAW �oAi� FORMS x�ww� IZ- r 9 <br /> '` (Nlailing Address) NOTE <br /> `iIOCKT N . CA 95215 <br /> (City, State Zip Code) <br /> cz�9� ti6� - 1oa� <br /> _ (Area Code-Telephone Number) <br /> - Sketch(Detaled plans may be submitted) <br /> P1-EASE_ SEE ATTACHED WORK PL/%%N pATEtI t�S SANVAk'*( 2p© 1 <br /> 3 <br /> The undersigned hereby applies for permission to excavate, construct and/or otherwise encroach on County <br /> Highway Right-of-Way on the Noes 1-t side of c)x Fo p-n AV E N v P: approximately <br /> 3 8G /mile NN\,.J\,.J of M\ 11 Cvy� i F i r�w� n ayE> rcx rot`< , byperforming the <br /> following work: (description of work'): ,mss a r AT'rt` N ov -;'-M Nr 'H Pv c r ,t F i�til <br /> GRt�V1V5� w✓aTE� Mc1v2TDG�L�\� �,i=1 r � ch`J- 22-C �cz.EFrvF �i �rT�.,�rN <br /> Bio AN(.) so FEET /�N17 rnw 2�\ ( SceEE vE, ficz EEN 7h Z,-,Nr) `Xc FTS <br /> Work will commence on or about r) -_) A0?S 1 a o for approximately ;n days. <br /> I the undersigned certify that I am the owner of the respective property, or am qualified to represent the owner and <br /> agree to do the work described above in accordance with the rules, regulations of San Joaquin County and subject <br /> to inspection and approval. <br /> v <br /> STAFF <br /> SIGNATURE OF APPLICANT - TITLE T <br /> DATE <br /> tf' l: <br />