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PLEASE PRINT: <br /> Date ' OFFICE USE ONLY <br /> To: San Joaquin County JOB# 'J$oos z_g REF# <br /> Department of Public Works APN CR <br /> EXP.DATE <br /> VALID Z <br /> (Applicant Name) STREET I�P✓trE�TO 3/� DRIVEWAYS: <br /> T. !� <br /> f <br /> AREANw <br /> QUAD <br /> TYPE �,G �1o�L:E - <br /> (g'ailing Address) FORMS <br /> NOTES <br /> gpn <br /> (City,State,Zip Code) y <br /> (Area Code-Telephone Number) <br /> Sketch(Detailed plans may be submitted) <br /> 1 <br /> The undersigned hereby applies for permission to excavate, construct and/or otherwise encroach on County High�.w�aX Right-of-Way on <br /> the �� �,-r side of i ,� =_,� .<� approximately. ` <br /> ofCf�e7limrle <br /> by performing the following work(description of work): <br /> Work will commence on or about.' '�� ,. <br /> ► '— A-� —i5& for approximately ? days. <br /> I,the undersigned,certify that I am the owner of the respective property,or am qualified to represent the owner and agree to do the <br /> work describedabove' accordance with the rules and regulations of San Joaquin County and subject to inspection and approval. <br /> / , <br /> Signature of Applicant-Title <br /> Date <br /> EIPUS-SV:7l;1"ASTEPPSIEUCROACN.'.:EIff PER;JTFFPLIC.4TI011.DOC(01100( <br />