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., <br />'. <br />Date OFFICE USE ONLY <br />To:San Joaquin County <br />.Departmentof PublicWorks <br />fG 1r=.~31/,~:3 7.3.2 <br />IAppiiCllli[Warne) <br />t{tI ~{;vJ e_t-t L....t.1\eJ <br />(MeiHilng Adillmss) <br />~'tbclc--to".cU\C(.s~olj <br />(Citi(,Stale,Zip Coole) <br />(.20<1)37 -t:q rx:d2€e,aoM <br />.(Ama Code.1eiephlllne I\lllrniJe <br />Sketch (Detailedplans may besubmitted) <br />JOB #'1~SJ~ <br />APN <br />EXP.DATE <br />VALID. <br />STREET <br />AREA <br />TYPE <br />FORMS <br />NOTES <br />REF;\! <br />CRt? <br />DRIVEWAYS: <br />~ee-$k::e-+~~ <br />C I'e~-to C-t{II ..f"".JC-o C::Z 0 q )1£'3-7/../2/LiB w., <br />72 He>(.{..\,:>be:9o Ie-Work 5-td r--t.s,e-r-~:;,lAQ.,1j f"e.t(t<.eSf" <br />~J ~•.'li'\.tt.1'".C,\etll~aV\ce1I rtU-&t-~wor-k ~U-I'H"~i..vrWfBt' <br />1M-b "i:k}i.No V'eIM.be-I"t hf't'il\.l\.-4.,••~~ <br />.!he undersigned here~y appliesfor permission tr;lxcavate,construct and/oroth?IWiseencroach on Counly Highwa R!ght-of-Wayon <br />[he S side of lu 1<:-1'tA..~~i'\I2J.approximately g 7 ee de &" <br />of TIA lZ "/II '"fA fA RL,LeU>:r ,by performing the following work escription of work):R.ep/4t'.-e,'De.-I:iec[nt4t;..•.¥t/lle <br />Work wiJIcommence on or about a -3a -I 16 for approximately 2.days. <br />lEN/)/-1.5:"'-/7 . <br />I,the undersigned,certify that Iam the owner of the respective property,or am .qualifiedto represent tile owner and agreeto do theworkdescribedaboveInaccordancewith.the rules and regulations of qan JoaquinCouniy and subject to inspection and approval. <br />R.I.~Da~'Signalure ofApplicant-Title <br />~t\CerrAA!.SERlIlCESlClEfllCAl.IPUS-SV.WK~\!IIS1ERJ'gIENCROACHMBrrI'FR!Ur APPI'1"011",",n"",mor", <br />~-.2.~-.2.016 <br />Dale