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( <br />"" <br />PLEASE PRINT: <br />Date '7 =5"~,.2~16 OFFICE USE ONLY <br />To:San Joaquin County <br />,-Departmentof Public Work$ <br />PG-~E.PM 3/1 S 3Cf5"6 <br />~J\'!JIl~ic;;mitfi~~mel <br />'1oLto 4J~S-t k.~e <br />(I\I1<JuffiUlg Address) <br />~1:pMe-f:ij Pi,t!1t q~~O'Lf' <br />(City,St~terZi!Jl Codle) <br />(;z"qJ 37~-q¥-3.2-lAma Code;•1"ele!Jll1ollll!l\100niJer) <br />Sketch (Detailed plans may be submitted) <br />JOB# <br />APN <br />EXP.DATE <br />VALID, <br />STREET <br />AREA <br />TYPE <br />FORMS <br />NOTES <br />REF # <br />CRti' <br />DRIVEWAYS; <br />:. <br />i <br />I, <br />,The underSignedhereby applies for ermission to excavate,cons\fuct andJorotherwise encroach on County Highway Right-of-Way on <br />the '2 'side of I'IM ;;-\"li'oL\1 approximately s ee He E: <br />of /V\,ekeCrI:QV'f M ,L Of)::J:,byperformingth'efol!owing work escription of work);, <br />Work will commence on orabou!7 -If)-2b [6.,.for approximately _2.days. <br />.£rJO /1-;;w-2bt£'.I,the undersigned,certiJi{that I am the owner of the respective property,or am qualified to representthe owner and agree to do the <br />work described abovein accordance with the ruies and regulations of san Joaquin,County and subjectto inspection and approval.", <br />iI'II <br />t i <br />I <br />rzJ0JL PtA .•;;.Sigrm[!Ife ofJlppiicall!'Title <br />~1:\CENmALEl"RIIlCESlCl.EflICAl,1PUtJ..SV.WRIIMS1ERPSIBWROAGf'./I,ENrPERMrr APf'llr:ATIOI1.lJOG [Q."Il3}, <br />7 -5'-;;<01 /' <br />Daie