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" <br />OFFICE USE ONLY <br />JOB#130.~d.'l,.REF#•APN CR# <br />EXP.DATE _I ~ <br />DRIVEWAYS;VALID,~'2.~.hl.DT I \,11 - <br />STREET W,f>'Ij.(r<d..* <br />AREA Z,~tLe"QUAD N~0 <br />TYPE ~u'f/~, <br />FORMS ,,7tJ.~, <br />NOTES J , <br />To:San Joaquin County <br />-Department of Public Works <br />fG It=.R~-511,i 6 L\;S5- <br />IAIlGJiica,it n~l!me) <br />PLEASE-PRINT: <br />Date fj -..3 -2016 <br />4b ~t)vJ 8-5';-l.A.1\e. <br />(I1.nai!iUlg f.\l!iWress) <br />S>t £1 cr.:..-t:o1\,rU\q ~-.:2CJtj <br />((;il1,State,lip CoiWel <br />l.20CC}:O -'1"fx:d2€!.e,co.~ <br />.(Ama Code.Tele[fJl1lme !\lllOlliJer <br />Sketch (Detailed plans may be submitted) <br />5 ee.-$ke-+~~ <br />Cl'e\V 'i"o 6411 .;':SClJ L20Cf)1£"3 -71-/.21 LiB r-cJ <br />72 Ht,(-u~be&or-e..-wC',.~5T~H-+Ss ~e\O j>&v~_.tJ t"ef'-lESf' <br />'\Rtt,l'"c.-leA.N'<V\.ce.1i yot-4..vU;i..work k\'~~I.(;H~,fel' <br />1'11l-btH""~AJtlv--~bs.",th~M"u"~p <br />-The undersigned hereby applies for permission to excavat ,construct and/or otherwise encroach on Counly Hi9=i9ht,of.way on <br />the 14/side of I-V v't""E!--I'.-'.approximately 2.2->-13 fee'i1e N W <br />of •5"&[';'''.'\-0~'.L'I\e.\,by performing the foHowing work (description of work): <br />R-e,pIAe-e'De-i:~rr'aIWe"R /bte $0:?Oa F Uu \"q:'t" <br />Work will commence on or about PI -~(;>.-16 for approximately z.days. <br />lEND i:l.-~~'-16i,the undersigned,certify that I am the owner of the respective property,or am qualified 10 represent the owner and agree to do the <br />work described above in accordance with the rules and regulations of Qan JdaquinCounly and subject to inspection and approval. <br />R2!~Dd~.Sign@tIlre of Applic@nt.Tille