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PUEASiE PRINT: <br />Date OFFiCE USE ONLY <br />To:San Joaquin County <br />.Department of Public:Works <br />P"'t 3,llq£1£";<tf <br />(Appiucalil !~amel <br />'-104tJ tVest LaIII e. <br />lIl~ami1!lAiJililress) <br />:S.t •..?ek -i:{),'1,e it qs;-;<0if" <br />(Cily,Slale?Zip Code) <br />(:201137E;-1tf!5Z1J\rea Code.Ielelll10lle !\!Imloerl <br />Sketch (Detailed plans may be submitted) <br />JOB II 7Xor,:)...(p REF II <br />APN CR#EXP.DATE ----11~7;,~h~""- <br />VALID.'71ih",OrO tilt Ith <br />STREET ~iIJ,tt,,1 r' <br />AREA tit,) <br />TYPE <br />FORMS <br />NOTES <br />DRIVEWAYS: <br />.The undersigned hereby applies for permission to eX&fte,conslrucl and/or otherwise encroach on County Highway ~l-of-Wal!on <br />the N side of E:rtlC~\ttV\t .approximalely /.I '-/fee~W <br />of N,q q ED~!'l+d~e.,Aljj i'l1 ro ,by performing lhe following work (description of work):,I <br />Re.i>itle::e Qe+er-t'e>CYi:ted'P",le.I <br />Work will commence on or about 7 -£2b t t{for approximalely 2.days ..ErJO 11 ~j;,--2bt-6 <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 County and subjectto inspection and approval. <br />i.I <br />6 -;2.t:J-::<61,{ <br />[Jale <br />1tt\CENmAl£ERVICESLCl.ERJCAlJJ'U!l:sV.WK\'.{,1,STER.P~\EHCROAGHM8,TPERMJT APPUCf,110N.DOG (DiUl3)