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IWPUCAIUJN fOR IEI\lCROACHMIE~,r PERlIIrol <br />OFFICE USE ONLY <br />JOB Ii _z..itlOS2.REF1t <br />N'N en if.EXI'.IlATE -'-~~}~--L6 --------------------'-------VALlIJ __1'9_:..lft..'(0 7-15-(6 f)l~I\JEW/\Yl):_..------smEET ,,.----AREA QUAD------,"lYrE ---FOHMS <br />NOTES <br />To:Sail Joaquin County <br />.l1op8lilllGIlI 01PulJlir:1N00ils <br />p (.,~:6 j''''l:5 (.t.22 'l11S-----(l"IlIJlfcmilN~me)---- <br />'~{.fJ~l(?IAJ8k •.~t tL'M>. <br />QlflellinlJMrlmss) <br />lidfCek-tbri\c.t~-q.~:2ot.1 <br />(City,Sfute,Zip Code) <br />.PlEASE I'RII\IT; <br />Dale -.1.1"....17 -.2.0 ~\.7_--_ <br />GS~I(;;;et~ql111i'fiD:::ietb1ai~le';fd~pla~n~s~m~ay~I:;:;)e;-;;s:;;jub;;;m:;r.lttr.;ee;n::::uJ::::::"):----------------'---------~ <br />.The undersigned hereby applies for permission to excavate,constructimd/or otherwise encroach on County Highway Right-of-Way on <br />the---lf.:.sideof ~~44IMJ,8eli,.,"ta M approximately '1.bO ~mile A) <br />of D e..c /<d<cf2 't=-t:ca.ltJ b1 .by performing the followingwork (description of work):, <br />.s af 3 <br />Wor!(willcommence on or about -for approximately I:=>.0 days. <br />I,the undersigned,certify that Iam the owner of the respective propelty,oram qualified to represenlthe 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 />~tD~.•.~«.Sign@tureof AppliCant-Tille <br />JL~t.?-~(!;)I> <br />D~te <br />l,tICElIfRA!.SEf(l,\CES'.Cl£R1C •••lJPlJllS'/J~K\\~S\S~CJi'l.fllrrw!Jr.•••rPllt:.\l)OIlDOC (Jl'l113)