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PLEASE PRINT: <br />2Ul/i ru.,~')7 'I)'",').I.')•....l.~.II _.J"-t J <br />Date OFF/OEi USE ONLY <br />To:San Joaquin County <br />.Department 01 Public Works <br />fr.r r}£.11'1 31[~1.1.:4 q 0 <br />IAppli~lilli~ame) <br />4oLto tV8-$i'LAMe <br />(Maiiil1!Jj Adllfess) <br />S"tnck-fot'1 ,6/t q~::::?.o¥ <br />ICily,Slale[lifll !Code) <br />L2oq:l sZs -'fil-5 <-lAma !Colle -ifeiefllhom!!\lllmbef) <br />Sketch (Detailed plans may be submitted) <br />JOB 1*7 :;oo5'J..-!p <br />APN <br />EXP.DATE <br />VALID, <br />STREET <br />AREA <br />TYPE <br />FORMS <br />[~OTES <br />REF # <br />CR# <br />DRIVEWAYS; <br />.The undersigned hereby applies for permission to excavate,construct and/or otherwise encroach on County Highw .Right-ol-Wayon <br />the Vd side of ./tl1erll-\IIla vli';1 Aile approximately -;;<';2.e ee'ile AJ <br />of V.e r-e>,"-t"'a .A-ve..>1:oekttW\,by performing the following work escription of work):, <br />Workwilicommence on or about 7-/8 -2b(i{for approximately 2.days. <br />ErJO fl-.2..o-26t6I,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 ruies and reguiations of San Joaquin County and subject to inspection and approval. <br />;;-27 -;;<61 i' <br />!Jale <br />1,l1CEfrrnAlSERVlC€SlClERtCAlIPUII-SV.WK\\V\STER.PSlBJGROACltV,ENT PERMIT APPLIGAT101WOt;(Oe/13)