Laserfiche WebLink
PLEASE PRINT: <br />Date €J-(-;z016 OFFICE USE ONLY <br />To:San Joaquin County <br />-Department of Public Works <br />fGI{3.~3.ltotbG"2£' <br />{Applicillit Warne) <br />t/(?10 w M.t ~fle <br />(Maiiilng Aililmss) <br />~-t i1 c,)c..:w",<!.-A qS;~b'I <br />(CitY,S1:ate,Zip Coile) <br />bO~373-q~32 r~d2e~e.~M-(Area Colle -Ieisphlllne 1\l1/lll1I~ <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 />DRIVEWAYS; <br />See,tf.:::;e+e1tt <br />Crew -eo e.tll ~~Co t~Oq)/f5~-7'121 <br />hOl.l,r~be~~lI-e-work.$-t;d.rls.<!.r-e,w ~t-iltt <br />,.Ro.}...Cl.e4-•...••••,,~'.e r"_i..L .D I•••••••,~TCJ •a.""~war-"'-0\-U,....~ <br />Mofl.-t"$"No 1Fewt.t>e..-r--t"-r-c'>Gl1k M.el-""u.• <br />.The undersigned hereby applies for pennission to excavate,construct and/or otherwise encroach on County Hi9~Right-of-Way on <br />the S .side of -1-14 if b-t ~d -.approximately 1.$s-.emile & <br />of C.UIf-V"'<,j I!d .,L Od>::r.,by performing the following work (description of work):R..eplAc-e.'De-terlntz;efeeP fbi€-.. <br />Worll will commence on orabou!g -it:;-t~for approximately -::z days. <br />fiE N 1)I:::l,-~3 -{6.'I,the undersigned,certify that I am the 'owner oflhe respective properly,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 andapproval. <br />R~D~•SiglJarure of Applicant.Title <br />8-/ <br />Date