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. <br />PLEASE PRINT: <br />Date 1-JB-:zoi 6 <br />To:San Joaquin County <br />'Depa,iment of Public Works <br />fG 4 F--RI1 311 q'.b 6 ?_3__ <br />1I'\ppli~3Iil~mnel <br />t{t'~o vJe-t-l-:~U\e <br />(Maiiiilg MlI~ess) <br />So'tD (;';'<::,:1;01\,itA q£,-.:2 0 <i <br />(CilY,Slale,lull'Coole) <br />(.2oq}:r7.3 --":::''1-32 l'x'r.beeje,co.'" <br />(Ama Co!!e.ifeielli1om!Number) <br />Sketch (Detailed plans may be submitted) <br />OFFICE USE ONLY <br />JOB!!75w9.(P REF!! <br />APN CR# <br />EXP,DATE 12-4//10 . <br />VALID.el'(I"10 IZ{t/t~DRIVEWAYS; <br />STREET Artie/it Alk..;,- <br />AREA '2tod<.-I-01 QUAD ~5 , <br />TYPE 8/"J!ei/Aw''l ...uit , <br />FORMS Si5IwJ.J . <br />NOTES I <br />.The undersigned hereby epplies for p~;;;;iSsion to excavate,construct and/or otherwise encroach on County Hi9~i9ht-of-Way on <br />the ~side of A rde,tle,Aile-.approximately.3.:2';-ee lie t= <br />of :5,.«,r(1i'ma!Ave.-,,$'TL2ttP;,1bc,},by performing the following work (description of work): <br />l?.e=fIA.e.e'De.-terfnr-atee.R !ale 2''''1'''t,,-Ar-c:kllt <br />Work will commence on orabou!6'-1'-16 for approximately ;2,days. <br />1;EIVD 12-2-i6 'I,the undersigned,certify lhat I am 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 ruies and regulations of San Joaquin County and subjectlo inspection and approval. <br />rG~[)d1J~ <br />'SignaMe ofApplicant-Title <br />~!:lCENTAAlSERVlCE5\ClERJCALIPUB-SV.WI(l.\!ASTER.PS\8.jCROACHII.8nPERMIT APPLlGATlOH.DOI:::{~1i3) <br />7-i8 -.'2..016 <br />Date