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PLEASE I?R~l\jr: <br />Dale 6-.2.1 2CP/t OFFICEUSE ONLY <br />To:San Joaquin County <br />.Departmentof Public Works <br />..1&iE PP2$"t>f.3)Cf376 <br />IApplicm-nt li~ame) <br />!.foLIo CUe-sf LaME <br />(I\IlaiHillg /-\lJIdmss) <br />S1:17 ck fedl -I t5fir q5:>"-;;'<0 if <br />(City,StOlIe?Zill'Cllli1e) <br />(:2"1)-s7s -xi/-:5 <- <br />(Ama Code.ifeiell'ilolle l\!!!il1~er) <br />JOB#73w5':)..(o <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 />Sicelch (Delailed plans may be submitled) <br />I <br />.The un.:!-ersignedhereby applies for permissionto excavate,constr,uctand/or oth~rwise encroach on County Hi9=:;i9ht-of-way on <br />the ~Sideof .5L &1/.,bel "'-if .:;.a/me.approximately .2 0 .ee Jle /V <br />of e &I a I'b ;;+~£to ~.s--i-6fl ,by performing the following work (descriptionof work):, <br />~t\C8IJRALSERlt1CES\CLERlCAlIPUB-SV.WKI\!I\SlERPS18,GROACHII.El,T 1'8~Mrr APFLICAllON.rJOG (iJ'!/13) <br />b-::?(-::<616' <br />Dale <br />I <br />II <br />" <br />Ret>itJte.Co'l~re:te.r _. <br />I)E'5/k .5.a I ,'ve 8').,--:i ><.'.IF!W f'a.-I,-,\ <br />Workwill commence on or about -for appro imately.3 days.. <br />EtJ'O H-IF":""2L';{.l . <br />i,the undersigned,certi1jrthat I am the owner of the respective property,or am quailfied to representthe owner and agreeto do the <br />work describ~d above in accordance with the rules and regulationspf San Joaquin County and subject to inspection and approval.