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PLEASE [PRINT: <br />Date /2-2-.2015- <br />To:San Joaquin COunty <br />.Department af Public Works <br />f Cr J FE PM 31//lett 83 <br />(t!\PIJ!i~!Ii~<J,""~) <br />/.{"t{0 We.$t L.tUI e... <br />(OO1J~~D""£1M<Hress) <br />~tot!-Ic"fol't ~Ft-q5:z.ot{ <br />(tiltJl,St.rie,ZilUl Ciloo) <br />La.oq)-3 Z3 -Q'l3 2- <br />'1AIllil tooe -T!l!epi1oili!!\!Mmber) <br />Sketch (Detailed plans may be submitted) <br />tee.A t1acJ..ed . <br />OFFICE USE ONLY <br />JOB#23000 REF # <br />APN CR#EXP.DATE G-/-(r,VALID Jj&T~S~DRIVEWAYS:STREET t~ <br />AREA "(QUAD A <br />TYPE Bare ., <br />FORMS S5W~/R?CfIIIOTES <br />. <br />The undersigned hereby applies for permi~on W e~cavate,construct and/or otherwise encroacli on County High~Right-of-Way ontheA1.side 01_c.O T TA ~t:t2~L approximately :2 CPO ~le g- <br />01 6ua r-d Rtl...,LaD:r.,by performing the following work (descriptio-n-ol-,w-o-rk-):, <br />Work will commence on or about 12 -.28-';>/7/<: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 10 do the <br />work described above in accordance with the rules and regulations of San Joaquin County and subject to inspection and approval. <br />gD~SIgnature of Applicant.Title /.,)-~-~('J I>:Date