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AUG- 38-2811 11:.'1 From: To:2894689324 P.2/3 <br /> AppLICATION FOR XVCROAC 'x3T pxRMST <br /> �LF.A9E PRINT: <br /> Rate ti. ) f-a 4 I arviek: yrs$ ONLY <br /> T0: San Toaquii. County a013 #_L'"`� REF # <br /> Dep irtts.znt c; Public Works A:?N M ## <br /> L.1i0ti..l,... VALIn f TO DkIVEWAY9: <br /> (Appxic t Nme) STREET <br /> MEA <br /> )mailing Addrean) eORMS _ <br /> NOTE. <br /> Lr rdkn CA <br /> ���� (City, Statc, Zip code) <br /> (A,raa Codr6 - Telephans Number) <br /> Sketch ()etaid.ed plana may be submit ted) <br /> The under;;.igned hereby applies i'or p.7rjjjif sjnn to excaVatc ee•uitruct and/ox <br /> otherwise encroach on County Uigaway Bight-cif-Vay an the side of <br /> approximately <br /> of _ _, by 'perfoxming the <br /> following worx (deaaription--411 ;ork) • ,t2 Q- t �S�: IAIn <br /> �,i a �� tom-�l 1S�Y�a�� • l 1��, 2� u� . <br /> Work will comman=:e or ab, ..r. �f^ �b , 2Q .} i7�r appy©ximataly <br /> — days' <br /> 1, the underaigned certify '.hat Z mm t 1a owner OL _ .° tes?ea_i-a propa,-ty, Or a.� <br /> g1.;alifaed to represent the Owner and agree ':o 114; ,_hg work described above in <br /> aoogrdanca with the r,_tlto, ::egv',ation2 cif San Joaquin County and aubjeC-, to <br /> inspectio:: r.rd approval . <br /> giQ�riature of Agnlloonc �x:le date <br /> Ne9?ce. sS1m1�8Cw9L f/0�� <br /> 9 <br />