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Date <br />PLEASE PRlMT; <br />C'-25 -,2.CP/6 OFFICE USE ONLY <br />To;San Joaquin County <br />.Department of Public Works <br />fir)£.A_13!l6'Ot/31 <br />IAillllic~l'ill~all1e) <br />!.foLIO tV-esf Lt.r.I'1t'., <br />(Mai~il1!lAllllre,s) <br />:f,"ttz Ck -t£)e'l d 6 P,q5>«-::<'0if <br />(Cily,Slale:Zip CllIle) <br />(2 ocr J57.:S -'it/::5 .:<.lArea Gm:le -ireielliJlllle IIIlIImller) <br />Sketch (DBtailed plans may be submitted) <br />JOB #13&iJl.fJ.-{p <br />APN <br />EXP,DATE <br />VALID <br />STREET <br />,~REA <br />TYPE <br />FORMS <br />!~OTES <br />REF# <br />CR# <br />DRiVEWAYS: <br />, <br />,.The undersigned hereby applies for penmissign to eJIQav,Ilte,construct andlar otherwise encroach on County Highway ~t-of-Way on <br />the N side of W t3 v-t,f e l?!.d'.approximately;:!p :2 ?fee~..W..... <br />of !Tot'k18\"1:'Q •.',gtl ,S I ()c~fs::TotJ ,by perform ina the fallowing work (description of work):,I v <br />Worl(will commence on or about '/-.J"r -2bt 6"for approximately If days, <br />EtJ'O 12.-31-:Mt-t' <br />I,the undersigned,certi(y that I am the owner 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 subjectto inspection and approval. <br />b -2..3 -':<61,{ <br />D@!e