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PLEASE I'RIMlf: <br />Date OFFICE USE ONLY <br />To:San Joaquin County <br />.Department of Public Works <br />fGIf=.~~IIq 0 l.(~O <br />IAppiicaoil~me) <br />'io1{)vJe-tt 4l\e <br />(MaiHiilg J.\llilress) <br />~'t tI clc.--to".e.A qS;~()I{ <br />(Cill,Stile,Zip Code) <br />(20t()37 -Cf,fX'd2€e.,coM <br />(.lima Code -I eiepholJe NlIIlIl1Je <br />Sketch (Detailed plans may be submitted) <br />JOB#Uoo5'J.--G. <br />APN <br />EXP.DATE <br />VALID <br />STREET <br />AREA <br />TYPE <br />FORMS <br />NOTES <br />REF # <br />CR# <br />DRIVEWAYS: <br />72..HNt.\;:;>b~re-.Woe-ok:5-td r-f.5,C-r-elO j>lArt.l/F"effL<esf" <br />\IR.v'"c,lecu-ttlAce,lI Tt';e--~~wor-k du.\'~Lort\fe-I' <br />,'Vi.t>eH~~AJ"Ve-IM-be.-"\"k~M-.it.,i"~, <br />.The undersigned hereby applies for permission to excavale,::~1J!>tfjlct and/or otherwise encroach on.County Highway R.1J1b!-of-Wayon <br />the W side of Tr--e *'b VA.'4 ~approximately 12,.(feelf~_S __ <br />of (1.A-/'2.,LJJe:J..e :G1'XL,by performing the following work (descriplion of work):R.ep/A.e-e'DM.ecrnbde-<P /hIe 170.>Q Tr-e;:\;l.elw~_ <br />Work will commence on or about B -3?~l6'for approximately ,:z days. <br />~ND I-~()-17 .I,the undersigned,certiJi{that I am the owner of the 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 and approval. <br />R,,~Da~'Signature ofApplicool-Title /3-2.3-<.016 <br />!lale