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!'lEASE I'PJl\lf; <br />Date OFFICE USE ONLY <br />To:San Joaquin County <br />.Department of Public Works <br />fG If3.&t.5 r 1,t15'2 B b <br />{Applicali[~ame) <br />1tI ~CJ LAJ e-tf:L.A..l\e <br />(Miliiirlg Address) <br />~'i;0 ~-to 1\,<1A qG".'::!.0 «j <br />(Ci~State,Zip Code) <br />(?o'1)3?3 -Cf1f32 fX-d2€p5:ie,"COM <br />(Area Gode -ifeiejlholle !\IlJm~erJ <br />Sketch (Detailed plans may be submitted) <br />JOB #73005d..~ <br />APN <br />EXP.DATE <br />VALID <br />STREET <br />AREA <br />TYPE <br />FORMS <br />NOTES <br />REF # <br />CR# <br />• <br />DRIVEWAYS: <br />j ee-~f.=.+e-.&. <br />C relV -to Ctt 1/.of -:s CO C2 CJ q )1.~.3-7LI.21 £..is t"Z/ <br />I:L t-L.nu::t be&o re.-Wo,..i:.5-t~H"-f.s,C-r-eIO j.fNt.)/!""'eft.<.eSf' <br />-'..fHR.-u'"e-Iecu-CH'\C-e"TOr .oL~wor-k a.-U.I'HI\..;l LvcrAfe-f' <br />oM-bt'\-tk~tVaV""€--\,,,,,"be-I'"T hf'LI MA,'~~, <br />.The undoersigned hera~y applies for permission to ellCBvate,construcl and/or oth?rwise encroach on County High';'ieY,.R!ght-of-Way on <br />the N side of OfAWI Rd.'.approximately a2S":~Tlile NW <br />of ;;,he{>,Gore"A"I ,T ('4 ",,*.by performing the following work (description of work):R.e-flA.e:ee De.-t.errnf7;:.l;te4 /'2!e fJl,;;.to c ,~S-O$7 .s kM+e.{' <br />WorkwiJIcommenceonoraboul $-3[-/6 for approximately .:2 days. <br />t;;NJ)l-lJtr I 7 .I,the undersigned,certify that I am the owner of the respedive 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 subjectto inspection and approvel. <br />v2.,-kl Dd~'Sign@ture of Applicant -Title 8-:23 -<.016 <br />Dale I