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PlEASE !PRlI\IT: <br />Date b '-'),7 -.';:La>/6 OFFICE USE ONLY <br />To;San Joaquin County <br />.Department of Public Works <br />ff.r i £Pt'1 b tl e t.i:5 2 •..) <br />(l\'l»jlli~~;illi~amel <br />lfoL/o aJe-sf uVit'- <br />(l\Ilamrull AIJ1i!ress) <br />f;'to (,~i<A:M'i ,,6ft q~"''::<.oif <br />(Cily,Stlile{Zip Coilel <br />Simich (Detailed plans may be submitted) <br />JOB #15:¥JSJAo <br />APN <br />EXP.DATE <br />VALID. <br />STREET <br />,~REA <br />TYPE <br />FORMS <br />NOTES <br />REF# <br />CR# <br />DRIVEWAYS: <br />.The undersigned here~yapplies for ermis~ion to excavate,construct and/or oth:,fWise encroach on County Hi9~R!ght-of-Way on <br />the S side of ..A _approximately It 955'e:l mile F- <br />of ~.v ,$>+O~k+6VI ,by performing the following work (description of work):,, <br />Work will commence on or about 7 -as -2b t is'"for approximately?.days,ErJO 1t-~(r26t.l .'. <br />..I,the undersigned,certify that I am the ownel'of the respective property,or am qualified to represent tile owner and agree lo'do the <br />work described above in accordance with the rules and regulations of San JoaquinCouniy and subjectto inspection and approval. <br />{-2?-~6t,t <br />[lale <br />" <br />1,I:\CEtlrRALs...<=RVlGE'SlC[£R1CALIPUB.SV.IVj(1\,{J\STER-PSIBJGROACHMENTPERMIr ,\PPlICATlOI~.OOC (W113)