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.,', <br />\\.",/;.:-.',;-.., <br />Sf"""1 JU,\CUi;'i C:C~)f!TY <br />~"lR i!'~J?O P'~.,.I f'LU U vl..';"'-Ii L',!) <br />Date <br />PLEASE pmi'll; <br />(~LO ~26;)/6 OFFICE USE ONLY <br />REF# <br />CR# <br />DRIVEWAYS: <br />JOB # <br />APN <br />EXP.DATE <br />VALID,'15 <br />STREET ~~ <br />ARE:~..'0u::Jf.~TYP_YI!« <br />FORMS '~ <br />NOTES <br />To:San Joaquin County <br />-Departmentof Public Works <br />-C.(,1 .,....''''f G-i E A'l 3 \\I IS.~)t" <br />IAlllllicamiK fi~l!me) <br />'-LOLlI)tVe-sf L.eU~e <br />(MauuiU1!j Alidress) <br />~.t",(;k -to iii ,6;.Y qs;-2.,0 if <br />(CiKjf,SK@le?ZilJlCoole) <br />(:201'1 s7:?"-1'i=:5 <-"(Area !Code ..11elelJllJillle l\!l!IiIIber) <br />SI(etch (Detailed plans may be submitted) <br />.The undersigped hereby applies for permission to.~xcavate,construct and/or otherwise encroach on County High Right-of~av ontheSQufYlsideofli1ft..Oct'!;'1(,,\".approximately 1-/.3 .leet!lie J:::; <br />of ~£("1 r-;=1'0,,-1;4l-1 e.,eel ,Lt>P.::r.,by performing the following work escription of work): <br />ReriAeeDe+el"t",c4'ted ,p"{e. <br />Work wiJlcommence on or about '7-F -2b t 6 for approximately.2,days. <br />EpJ'O1l-1!?-20t,lI,the undersigned,certiJi,r that I am the owner of the respective property,oram qualified to represenltl1e 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 />&-ti-Pu A ::..Signature ofApplicani ..Tille <br />(;$-20 -~':<6ttf <br />!Dale <br />~l\CEl<rnAlSER\IICES1ClERlGAl.IPUIl-SV.wK\.W,STERPS\8jCROACHM8,T PERMIf APPLlCATlON,DOG ~113)