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,. <br />2U'lbJUt I 4 Ali 10:05 <br />"lEASE PRINT:. <br />,,,".:J O"K S~,I'"ol i'\, <br />Date OFFICE USE ONLY <br />To:San Joaquin County <br />'Department of Public Works <br />fG If=-Pr-t :3 q qq 531 <br />IAllllli(;3ril U~l!me) <br />"tl1o w es'{:L..t..l\e# <br />(lMililii1!]Aliidress) <br />~-t &6}c..-to 1\,rtA q5".2.()'i <br />(Cilff,Sliille,Zij]Corne) <br />bo<:f}n'J1'3 rxd2 e <e,(!OI'" <br />(Ama Gode -Teiej!l1olle l\llIDlber <br />Sketch (Delailed plans may be submitied) <br />JOB #J$oo~().-Co <br />APN <br />EXP.DATE <br />VAliD, <br />STREET <br />AREA <br />TYPE <br />FORMS <br />NOTES <br />REF# <br />CR# <br />Aff <br />DRIVEWAYS: <br />.", <br />,The undersigned hereby applies for permission to excava7 construct and/or otherwise encroach on County High~J1,Right-ofcWay on <br />the £:side of I\l 'T u 1/11 ~'approximately-:2-[)C{!?@.et/mile ru <br />of P-T"kll$C">li"'W Rtf "LaD::r..,byperrOrmingthefOIiOWingWOrk(destptionofWOrk):l?efIA.-&e,De--terrOf?::Cfe,,,ll /0 Ie A/F 1:<10;;-AJ "Iu/!¥,f-.o <br />Work will commence on or about '7 ,-.2 7-I 6 for approximately ;;z.,days. <br />IE tv])11':":2.-0 -16 'I,the undersigned,certify that Iam the owner ofthe 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 subject to inspection and approval. <br />~Da~,Sign@llIre of Applic@Il!-Title <br />~t\CENJRAlSERIJ1CESiClERlr.AllPUB-SV.'Nl(1.'MSTERPS\E1ICROACHMElfT PERMffAPPLlCi\TIOIHlOG {~113) <br />7-11=~bt6 <br />Dale