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.: <br />PLEASE PRINT: <br />Date OFFICE USE ONLY <br />To:San Joaquin County <br />-Department of Public Works <br />fG!f3-fill 3 \~~S"b'6 <br />-IApplicanit ~a!11e) <br />tj &'10 uJ e-t-t l-Al\e <br />(llIIaiiill!lAddress) <br />5:'t"cl<=-WI,,c,A C(5"~ol./ <br />(Cill,Stille,Zip Code) <br />POcU3'73 -Cf't32 r><Zl2€'PfJe.,(0."l <br />(Area Go!lle -Telephone I\lllillber <br />Sketch (Detailed plans may be submitted) <br />JOB #7,o{)5d---c...- <br />APN <br />EXP.DATE <br />VALID _ <br />STREET <br />AREA <br />TYPE <br />FORMS <br />NOTES <br />REF# <br />CR# <br />DRIVEWAYS: <br />,5 ee-Sk-e-+<!-~I <br />Crew -to c...rell~~Co {-':<.otq),'1S3-7tj.2.I 4/6 -ft}7..:< <br />hcc.\-f"~be~tll-e-W 0 l'Ie.;;i;Glr-t5:.c~6 l..ttt I 1~e-~'1- <br />\l g01.\C (~l"lVt U'...I{:H:>i-lU\~W (J r-k:e{U1"1~~-uI.'VI~r- <br />Mo Il.-tk$"No V-eWl be-\~..tt,r-a'lf-k Ntet.I'U ._ <br />-The undersigned hereby applies for permission to excavate,construct andJorotheJ1Niseencroach on County Highway Right-{)f-Way on <br />the IV side of C!..a'!it'rt>o~(;~~approximately I ~5£"ee lie ,Eof:r,~&is-T6V1.f'=U s'ttJIikf"'i ,by performing the following work escription of work): <br />_R..eflA.t!-€'De-terllih:d-eei Ihk 'S~~£CA~r(f"'~- <br />Work wiJlcommence on oraboul B-to '-l6 fur approximately ~days. <br />-~ND l;:i --2._~-16 'I,the undersigned,certify that I am the owner of the respeaive property,or am qualified to represent tile owner and agree to do the <br />work described above in accordance with the rules and regulations of $an Joaquin-County and subject to inspection and approval. <br />R..~Dt~~'Signature of Applicall!-Title <br />B-1 --2016' <br />Dale