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�1=1=AQM <br />Date L'7 5" <br />l a: San Joaquin Gounty <br />Department of Public Works <br />(Apg�Picanf tare) . <br />(Mailing Addrdss) <br />(Detailed plans may be submitted) <br />r <br />The undersigned hereby applies for perrtlission to excavaf�, cansfruct andlor otherwise encroach.on Gounfy Highway Right o%Way an <br />appra mately ; 1,_o7c, feet/at -' <ST <br />or' S , 0 \ � CI P=A �- th \/ 1 E�' 1 .l N C r , by performing the following work (description of work): <br />�L f� LC r O c;! " k i) ,A P-1 iY) iA i A i10, . -r-u , o :1 1. , . , .— .A . <br />dig S <br />_' <br />Work wi[I commence on or about 1 kL�l Oq for approximately r/5 •1-c 116 <br />days, <br />1 <br />1, the undersigned, certify that 1 am the owner of the respective property, or am qualified to represent the owner and agree to do the - <br />work described above in accordance with the rules and regulations of San Joaquin County and subject to inspection and approval, <br />�r$le � r G) � C / /1/llril nC•�� t? , <br />-` 6i a_ a, tri o /v [? C rr� L_ Ice]) ,G t.._ <br />Fd:10ENiF2AfSERVICE51CL521CAllPt1ESV.WKVJA5IE4P51Eh�CR0A4`HA{EMPERAI1PAFpLICA110N.�OC (09!13) <br />sliri lig • <br />��- <br />OFFICE USE ONLY <br />JOB # <br />736677? REF # <br />APN <br />CIS # <br />EXP. DATE <br />VALID <br />0 // / /$ <br />DRIVEWAYS: <br />STREET <br />,r <br />AREA <br />QUAD <br />TYPE <br />,5 <br />trt <br />FORMS <br />NOTES <br />The undersigned hereby applies for perrtlission to excavaf�, cansfruct andlor otherwise encroach.on Gounfy Highway Right o%Way an <br />appra mately ; 1,_o7c, feet/at -' <ST <br />or' S , 0 \ � CI P=A �- th \/ 1 E�' 1 .l N C r , by performing the following work (description of work): <br />�L f� LC r O c;! " k i) ,A P-1 iY) iA i A i10, . -r-u , o :1 1. , . , .— .A . <br />dig S <br />_' <br />Work wi[I commence on or about 1 kL�l Oq for approximately r/5 •1-c 116 <br />days, <br />1 <br />1, the undersigned, certify that 1 am the owner of the respective property, or am qualified to represent the owner and agree to do the - <br />work described above in accordance with the rules and regulations of San Joaquin County and subject to inspection and approval, <br />�r$le � r G) � C / /1/llril nC•�� t? , <br />-` 6i a_ a, tri o /v [? C rr� L_ Ice]) ,G t.._ <br />Fd:10ENiF2AfSERVICE51CL521CAllPt1ESV.WKVJA5IE4P51Eh�CR0A4`HA{EMPERAI1PAFpLICA110N.�OC (09!13) <br />sliri lig • <br />