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PlEASE PRINT: <br />Date OFFICE USE ONLY <br />To:San Joaquin County <br />.Departmentof PublicWorks <br />fG/{3 &t 3 \l q 057 & <br />lJ.\pplica;ll[!i~~me} <br />1p q{)we-tt kf\e <br />(l\.llaW!'lg AdIi1ress) <br />.s 'tl1 61=-to".c!.-A qs,-.2 ()I.{ <br />(Cit;'SUlte,Zip Colle) <br />(2oCf)373-<:1lf32 fx:d2€.f{Je,C<?M <br />(Area Coile •.Telephone IIlUlill!Jer <br />Sketch (Detailedplans may be submitted) <br />JOB#13a25J---~.APN <br />EXP.DATE <br />VALID <br />STREET <br />AREA <br />TYPE <br />FORMS <br />NOTES <br />REF# <br />CRI.! <br />DRIVEWAYS: <br />• <br />• <br />~ee--.>ke,+~ <br />C relV '"to 6£{II .F"Sc;,,6 [2 ()q )1~3 -71.-/21 LiB w <br />/2 t-LbL-l-~~ber9-0r-e.-Wo,.-k.5--tdr--r.>~c..r-e-tD j>fNt..fJ I"ef~ <br />/::>.'--~•••f'li"tU'",c,letlr--C<.VI.Ce"lI rbt"a-VUi-WOn'-&VU-N"'~L(:)crAi''EU' <br />j'IA-oe,-tk..s.NOV'e..IM.bB-\'"thM<M ..u"~, <br />.The undersigned hereby appliesfor permissionto excava,te,construct and/orotherwise encroach on County Highwa Right-of~~on <br />the $side of L "Ire.-aa k.~d.approximately J 2 ee mile_=~-=~ <br />of ::r",,~k"T0IAe.Qa .,L I ,byperformingthefollowingwork escriptionofwork):,"-to~'L,'a <br />Work will commence on or about 'tJ-3d>....•z6 for approximately ~days. <br />I~rvI:>/...;.3",-I 7 ..I,the undersigned,certify that I am the ownerofthe respectiveproperty,oram qualifiedto representthe owner and agree to do the <br />work described above in accordancewith the rules and regulations of San Joaquin.County and subjeclto inspectionand approval. <br />~Dd~'Signawre ofApplicililt •.Title