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.. <br />PLEASE PRUllI: <br />Date 7-i -.:z.oI6 OFFICE USE ONLY <br />To:San Joaquin County <br />.Department of Public Works <br />fG I r=-Ptli .5\:+:2 6)7 '7 <br />IAp1'lliclill1'n~@me) <br />1tI ~{)vJ e-s.f:4,f\e <br />(Mlili!i119 Alililimss) <br />s>t C1 er-.--to 1\,d.,f\q !f;.::l ()1./ <br />(Ci,y,S,a,e,lip CollIe) <br />(20'4)373 -Cfl.f32 rxd:zep{1e,Cl?fVi <br />(Area Code.feleplJolle I\llliil!ler . <br />Sketch (Detailed plans may be submitted) <br />JOB # <br />APN <br />EXP.DATE ---~~~-~--~VALID. <br />STREET <br />AREA <br />TYPE <br />FORMS <br />NOTES <br />DRiVEWAYS: <br />.The undersigned hereby applies for permission to excavate,construct and/or othelWise encroach on County Highway I)jg!1t-of-WifY on . <br />the g side of uJLl ~tRd..approximately ()";<5'feetl~./If. <br />of ....tia,;,.".UA.'4.c Ave t.ii\I!l..B.'R '.'0""11 ,by performing the following work (description of work):-:r t'\~b\II Ne.-W Pt.I:':!.17 eB8 LW.!jn er-6:d <br />WorkwiJl commence on oraboul .,-I t;=-2.'"16'for approximately 2.days. <br />/E /\;'J)li':"'.2.o -;:l.o 16:.i,the undersigned,certify that Iam 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 rules and regulations of San Joaquin County and subjectlo inspection and approval., <br />~J.Da~ <br />'jigniit!lre ofApplicant.Title <br />I.t\CENIRALs.ERVlCfSlCLERlCAlI."UI>-SIJ.WK1MASTER.PSIEI~CROACllt"ENTf'ERMlf Af'PLICAll{JIWOG {D9/1:J} <br />7-/-Z,bi6 <br />!Jale