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• <br />.. <br />PLEASE PRINT: <br />Date .2CP/6 OFFJGE USE ONLY <br />DRIVEWAYS: <br />-REF #7300s;).-c" <br />CR# <br />I~I /4> <br />7 IS (iP TO II I lip <br />Alffm:'JM .ltJd/QUAD N~{tit !#!4umerrf'?:IwuY• <br />JOB # <br />APN <br />EXP.DATE <br />VALID _ <br />STREET <br />AREA <br />TYPE <br />FORMS <br />NOTES <br />To:San Joaquin County <br />-Department of Public Works <br />pf:riE.PM 3/18 £-1g,i 2. <br />IAPIl~iCli!uit mI~mel <br />'1t;LI{)fJ.J~>'t la'tvi:. <br />(MiluHiY1!j AIlill~"ss) <br />5:>1:"ck of tH!'j ,6ft qtr.:2..",Jf <br />(City,Stinle;Zi!Jl Colile) <br />(2:(ttl)37 ~-'it/:~.2.-lAroo COilll -I eieJlll1l]lIe !\f1llJiJ!!Je~) <br />Skelch (Delailed plans may be submitted) <br />-The undersigned hereby applies forpermlssion to excavalJ/,conslrucl and/or olherwise encroach on County High~i Right-of-Wayon <br />lhe _<::s/deof At/nr,';;"'.'1 RLf/_approximalely 871'@!llJIniie_I1_J __ <br />.of N -:r 0 t,k To1'\-e I~A -,,U.M;I;;(,by performing lhe followingwork(descripiion of work): <br />J ,ZiPdI". <br />Re.eiAc.e..'Pe+er-tM,,--z-ted -P"fP.J :5.2-~7 "i-'f/b'itS'60, <br />, <br />Work willcommence on or about 7-18 2.bll{.forapproximalely :z days. <br />ErJ'O /{-;W-::wt£_I,the undersigned,certifythai Iam lhe owner of/he respective prop~rty,or am qualilied to represenl the owner and agree to do the <br />workdescrib~d above in accordance withthe rules and regulations of san Joaquin-County and subjectlo inspection and approval. <br />!Z4JL DCA";.Sigi1@t!!re of Applic@i1t"Tille <br />'7 -5"-;;<ol,! <br />Dale <br />.,