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•r <br />fi"IJEJ\SIEfi"~!I\rIi: <br />Date iJ <2 -.2016 <br />To:San Joaquin County <br />,Department of Public Works <br />ftP!\>\(I>q 6q3 <br />«tf~~-if'~cl.~W[lm~l) <br />5 '£"uc.-k::,~e;>,lIj I e-.p.qG"";;t I:)Il.{- <br />(Coljf,stJlte,Zi~GI!llf!ile) <br />-'ZI!J'i.)n?-Qq32.. <br />(Ar;;<liCillill~.TeleiliBloHle~jll!rnili~r) <br />Skelch (Delailed plans may be submitted) <br />tee.,':l..'t+q.ehed <br />AREA <br />T'fPE <br />FORMS <br />NOTES <br />OFFICE USE ONLY <br />,DRIVEWAYS: <br />,',---- <br />, <br />The undersigned hereby applies for perm,ission to excavate,construct and/or othelWl,'se encroach on County High~Right-of-Way on <br />the S sideof W5t()Lte-wPi $1 appl'Oximately 220 ~mile_E __ <br />of 7b.t2'"(\-iOtA ~,,orb 04'1\'-/"0'1 .by performing the following work (description of work): <br />Work will commence on or about for approximately days. <br />I,the undersigned,certify that I am the owner ofthe respective property,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 />;e.o~ <br />Signature of Applicant -Title 3-.2-~oI6 <br />Date