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Date <br />f'lEASIE PRINT: <br />b-21 -.2(9/6 OFFICE USE ONLY <br />To:San Joaquin County <br />.Department of Public Works <br />fir.)£'PM 311'1'o"lQOIApplil:a,lil fi~ame) <br />lit/Lit)tV-esi'LaMe <br />(MaiHi~!lAilrdress) <br />!f;-tllck-tot1 ,6ft 1:;'-:<'0'-1 <br />•(Cily,S!1nle;lull Corde) <br />(,:2011 573.-rtf:5 z-rArea Cotie -reiellilmle I\IllIl1oer) <br />Sketch (Detailed plans may be submitted) <br />JOB#13005J.4 <br />APN <br />EXP.DATE <br />VALID. <br />STREET <br />AREA <br />TYPE <br />FORMS <br />NOTES <br />REF# <br />CR# <br />DRIVEWAYS: <br />* <br />* <br />.The under.signed hereby applies for permission to excavate,cons~r ct and/or otherwise encroach on County Highwa Right-of-Way on <br />the uJ side of N,e,l evqeo1'£~-_approximately .ee He .£ <br />of £;:.t-I A..r fA ~L.J',r ~;o ,by performing the following work escription of work): <br />Rep!A~e Pe:ter-toc:/rted .P"le tl1B1 I\.J (ijerI1Bflt<RiI <br />Work will commence on or about '7 -£2bt i{for approximately ;Z.days, <br />E(I.)D /I-lr--26t-l <br />I,the undersigned,certify that I am the owner of the respective properly,oram qualified to represent the owner and agree to do the <br />work described above in accordance with the rules and regulations of San Joaquin.County and subjectto inspecllon and approval. <br />6--:::<I-:::<01 6 <br />liJate <br />~t\GENJRAt.sERIlla:S\Cl.ElllCAllJ'UB-SIJ.WK\\'lAS1ERPS\ENCROACHMEllTPEIt'.IT !lPf'LlGA1JOI~.(JOG (GEI13)