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OFFICE USE ONLY <br />JOB#1;O():sa-"~REF# <br />APN CR# <br />EXP.DATE Ila;.; <br />VALID.:1fJtb ;;ro 41/)~DRIVEWAYS; <br />STREET '*'2id:.~~ <br />AREA 1dnA".QUAD!!l " <br />TYPE ,. <br />FORMS :j~,,~f1J/~ <br />NOTES <br />4oLto ({JeST Lav1f. <br />(MOliHii1!l !-\IJ1!11ress) <br />!>til ekftH'1 ,617-157--:<'0 tf <br />.(City,State?Zill Colle).' <br />b.o'(1 57.?>-'1Lt 5 <-1Are@ C!!de -IIeiellll10lle m!!il1~er) <br />P!.EASE PRINT: <br />Date &.-.2.(-.2CP t 6 <br />To:San Joaquin County <br />-Department of Public Works <br />efri£A'I 3,II~Sb38 <br />l!-\rlllicaITiin~~me) <br />Sketch (Detailed plans may be submitled) <br />.The undersigned hereby applies for permission to excavate,co:tru9t and/or otherwise encroach on County Highw~Right-of-Way on <br />the W side of :S"•••J..•.TtH\F f2tL approximately If!:'-(~ile II! <br />of &1.0''-I*~-ko".PI?ad ,L t'0 d e'1 'by performing the following work (description of work): <br />Re.elat;e,Pe:ter-toc,zted -Pr;tp .2 I)q ":TackTItle ,5:!dI <br />Work will commence on or about '7 ~.£"""2b t K for approximately .2 days.E fiJ 0 It -IS -20 t-l <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 />!Z~DC4 .•~SignatlJfe of Appiul:~l1t -Title <br />6-~(-:::<6 t 6" <br />D@te <br />" <br />~t\CEflTRALSER\IIC€SlGLERlCALlPUg.sV.WK1MASlERPS'BlCflOi,Cfll/,ENT pF.RMrr APPLICATION.DOC [IJ'}/13)