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PLEASE PRINT: <br />Date <br />To: San Joaquin County <br />Department of Public Works <br />(Applicant Name <br />� t�kMo+% �,O\j e <br />(Mailing Address) <br />APPLIL AI 1UN F"UK ENCP.CJACHMEN I ft IVII I <br />�4')C <br />(City, State, Zip Code) <br />(Area Code -Telephone Number) <br />(Email Addre s) <br />OFFICE USE ONLY <br />JOB # REF # <br />APN CR # <br />EXP. DATE <br />VALID TO DRIVEWAYS: <br />STREET to <br />AREA QUAD <br />TYPE <br />FORMS <br />NOTES <br />Sketch (Detailed plans may be submitted),• r rt;�� • <br />�``ri, STae. T <br />�l✓f � �+N J. • �1 p <br />V� <br />The undersigned hereby applies for permission to e cavate, construct and/or otherwise encroach on County Highway Right -of -Way on <br />the t�0o>r�.� side of ��. approximately �� feet/mile <br />of 4,49tW14rby performing the following work (description of work): <br />Work will commence on or after <br />for approximately <br />days. <br />I, the undersigned, certify that I am the owner of the respective property, or am qualified to represent the o,vner 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 />-Title <br />PEPNIT APPLICATIOPI dnc (OBI09) <br />Date <br />