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PLEASE PRINT: <br />Dale 11--30 -.2._0~1_G"_ <br />To;San Joaquin County <br />.Department of Public Works <br />f &~G.f~"1.3 Jlii 00 31~__ <br />(Al'plicali[Name) <br />l.,{tfrP..i{;)iAJes".'+l~\I\e_ <br />(Manllin!!Aildress) <br />.G '1:~ek'f8i\.,c.A-qS~o '-I.(City.Sl!Jte,Zip Colle) <br />(Ztfl'L))7£-q..,g2..,..'ltd:?(f,f?al€c """"0'".(Area Code -lelephmie Nllm!ler) <br />Ske Detailed plans may be submi e <br />OFFICE USE ONLY <br />JOB I!(f~1~~-b'REF # <br />APN CR# <br />EXP.DATE S-I(,--2016 <br />VALID 2.-It:-~("TO S rS 2.o~DRIVEWAYS: <br />STREET 'S cN\.CX c....«.;, <br />AREA i'"'~QUAD -3 E .TYPE <br />FORMS ;;:~Ge I.Ml\l~10"0 <br />NOTES <br />• <br />.The undersigned hereby applies for ennission to exca,vate,construct andfor otheIWise encroach on County Highwa Right-of-Way on <br />the Nltz side of .approximately 5>'eet!He5g-/,., <br />of (2;".Br,If t :harl'lA .'OiJ-#611 ~{(J byperformingthefollowingwork escriptionofwork): <br />______~f?,~••_,~1o.c e PI?Ie <br />Work wiJIcommence on or about ./2-1-20 1"-for approximately 120 .Da'fc days. <br />I,the undersigned,certify that I am the owner of the respective property,or am qualified to representthe 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 />.f..4ul tf2c,...•-,.Signature of Applicant.Title /t-30 -.2t2f~ <br />Dale