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fi>llEASIE fi>RII\I1: <br />Date J ~2 ~2c>!6 <br />To;S@nJoaquin County <br />'Depilllmei1[af PuiJlja WalKS <br />_If){r ~J~ieilfl 3 J I 7 D1;<t./ <br />(~~c¥n~.:;~tT~8[;~m:~p <br />5 t&\dJc \~,f)(1U 11 e,,~~.t1i'~~D~I~~ <br />(iCil:jr,Si~te.li[l)l Ci]lD!e) <br />l:uA)i~<T!f-<:1 q S2- <br />(Area iC(llille.IfeiefilJ)j(li1E!~jl!ffi1lile") <br />Sf(61ch(Detailed plans may be submitted) <br />~ee.a:t~@/.ehed <br />OFFICE USE ONLY <br />JOB#73oo'5'J.-4-REF # <br />APIII CR# <br />EXP.DATE 6\,~ <br />DRIVEWAYS:VAUD3\1s\l("\0 ]{l{lb <br />STREET _1-Il\Q.Ne'i W.___~'_, <br />AREA LoDI QUAD No.),; <br />TYPE ~~~ku~--FORMS <br />'~'--NOTES <br />The undersigned he,reby appfies for penmission to exc@vate,constructand/orotherwiseencroachon Counly High~y,Right-of.Way on <br />the AI 'side of IN H A rf\~LtJ approximately ;.roo ~i1e W <br />of N Dp ",'>-RD ,LO OJ ,byperfonmingthefoflowingwork(descriptionofwork): <br />Work will commence on or about 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 described above in accordance with the rules and regulations of San Joaquin Counly and subjectlo inspection and approval. <br />;e.o~' <br />Signature of Applicant.Title