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1,'. <br />2"'1°"'I""7 p,..,3'!3u0J'.."i:;L ~'i."~~ <br />Date <br />PlEASE PRINT:t -;27-..2&/6 <br />To:San Joaquin County <br />.Department of Public Works <br />ftri£p~3d6 H3BD <br />IAp[iJlic~iiKk~.me) <br />LtC/LIt)tUe-s-r LaMe <br />(M.iliHlg A!lJiD1ress) <br />~1;v I;<k-f:o t'l ,(3.ft-q5:>~::<,oif <br />(Cily,SI@te?Zip COlle) <br />f20ql 375 -iLl-55 Z(Am@ Code -TeiejJl10lle rJilm!Jer) <br />Sketch (Detailed plans may be submitted) <br />DU'T ..:'::Hj"L1C WORKS <br />OFFICE USE ONLY <br />JOB #1'300SJ.<.:,REFit <br />APN CR# <br />EXP.DATE if,IN., <br />DRIVEWAYS:VALID.'1jj't.b",rto ~4J;t.> <br />;STREETtJ.;J<?• <br />AREA r!1 QUAD N~, <br />TYPE , <br />FORMS ty4:0nLAi <br />NOTES <br />.The undersigned hereby applies for permission to excavate,construct and/or otherwise encroach on County High~Right-of-Way on <br />the __E sideof 1AJt,,'1"e L.c<.Vl€.approximately 2!-bc;}~ile ~ <br />of L e.e-c.,.r ,G'-tQ I:AS::7',M ,by performing the following work (description of work):, <br />Reelace.'Defer tOC4.-ted .p",le, <br />Work wili commence on or about '7 -I6 -2.b t if".for approximately days.E rJ 0 9l -'Acr-;U}l£. <br />I,the undersigned,certify that I am thlrOwner of the respective property,or am qualified to represent tile 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 />MJ,Dc....A~Signature of Applicallt -Tille <br />~t\CENrAAlSERVlCSb1Cl.ERJCALIPUB.sV_WK1.\lASTEItI'.sI£NCROACfa,:8n PERMrf APPUCATlOiy,DOr::(C!!I13) <br />6'-27 -.;<6/.t <br />Date