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,' <br />PlEASE PRINl: <br />OFFiCE USE ONLY <br />JOB #'1~65~REF# <br />APN CR# <br />EXP.DATE tlhlJlP . <br />VALID.I"k<t/'iP I TO II},fUr>DRIVEWAYS: <br />STREET IJII'&r6$IJII~'r I * <br />,lI.,REA i:;3A QUAD ~" <br />TYPE "~1.Vtit::£-~ <br />FORMS 9Sf,•NOTES <br />To:San Joaquin County <br />.Department of Public Works <br />J-.6:i t=A'l 3,,/i7 7 t?"of 4. <br />IAjljllicani,!~<me) <br />Date <br />l.l"LIt)tV'B-S-r La&~-e_ <br />(Il~amil!lf.\0J111~e5s) <br />Si:t7 (:J<..-f:M'i,6it qsr.;<0 If <br />(Cily,Slille;Zijl Collie). <br />(20q1 s7s -1'1:5 Z(ilrea elliJIe -leiejll10ile I\!lIlmoer) <br />Sketch (Detailed plans may be submitted) <br />.The undersigned hereby applies for permission to excavate.construct and/or otherwise encroach on County Highway Right-of-Way ontheWsideof..£:A,,ter-05:Av-e.-.approximately 3S0 ~i1e ~ <br />of &u elf'/I)f~Ave,s-[??c'fcTOA J ,by performing the f6110wingwork (description of work): <br />ReelAc.e-De+e •••tcc;rteCl P",lp1::<"'11 >"Atllte-ro$:.Ave::L,r:.~•.H!~H-ar:d -c:i'I.Wle a-t• <br />Work will commence on or about {;-;),6 -2bt 6 for approximately '6 days. <br />ErlJ'D £1-Ii?-20tlI,the undersigned.certili{that Iam 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 subject to inspection and approval. <br />&AJL D&t,,~Sigl1atllre of Appiicai1(.Tille <br />t -2£}-::<61 tf <br />Dale <br />~t\Gam<A!.SER\.~CfS\CLERlCALI!'UIl-SV!r'lK1.\!ASTERPSlE1iCROACIfMEHT,I'ERMrr APPLICATION.DOC (ne/13)