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PLEASE PRlI\IT: <br />Date OFFICE USE ONLY <br />To:San Joaquin County <br />.Department of Public Works <br />fGlfE Rlij gl\55"620 <br />IApp!ica.nt n~ame) <br />4cd0 w M.t L.<t.ne. <br />(MaiHilllg Mdress) <br />.~>t'"c.}c..i;o 1\,e,A q.£"~0 'I <br />(CitY,Slate,lip Colie) <br />JOB#'13oo';'J..-(." <br />APN <br />EXP.DATE <br />VALID <br />STf<EET <br />AREA <br />TYPE <br />FORMS <br />NOTES <br />DRIVEWAYS: <br />, <br />Sketch (Detailed plans may be submitted) <br />5ee-~f.;::;e+dl <br />C.rew -1:0 c..ell ~:r-Co {20C}),qs~-7¥21 -'16 -It!7..< <br />h{jLLI'~!;.e~l"e-LV()f'k $i;Gt.r-ts:.CI"'eW Gt..,dl l~e~+- <br />\1 R~.,Cl~nvtce.'I'-Fbi-dllt!3 WCfr-k:4ur-I~'<fi w ~~It1;;;r- <br />M.ofl.-l:;k~Nov'ew..be.,'-tkr-Cltlf-k N\.et.l'&t.,. <br />,.. <br />,The undersigned hereby applies for permission to excavate,construct end/or otherwise encroach on County Highwa Right-of-Way on <br />the N side of /V".r-"1.et.'L AVE?approximately f 3 j;"'emile W <br />of !>ib[--er,A v',<{;-to e-k +6",by performing the following work ascription of work): <br />l?..ep!A.t:4i-De.-tec ,ht>:d"e4 /h Ie I (I>&"7 .•"J••,..".\0$1'\0 A II <br />Work wiJI commence on or about S -f 2.-I6 for approximately 2 days. <br />It:NJ)i.:2.-~:3 -l6 .I,the undersigned,certify that I am the owner of the respeCfive 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 San Joaquin,County and subjectto inspection and approval. <br />, <br />~t\CEMrRALSERIIlCESlCLERlCAl.ll'lJB-SV.W[(1.\lASTER.!'S\HICROACIlM8fTPERMlr API'Ur::ATlOliDOC {Ll'2It3)