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PLEASE PRiNT: <br />Date .3 -2 -2C>16 OFFICE USE ONLY <br />To;San Joaquin County <br />.Department of Puillie Worke <br />f&H=P"")31\.8Lt!::loJ-~t\\{C,~Ir.~,~~:,~.~\f.lm:~l! <br />5tpt1-k toVi I c!-A q~~()y- <br />Il£:i~,Sl~re,Zil'l CIQJil1I1l) <br />Sketch (Detailed plans may be submitted) <br />See a:Hot:{e.hed <br />JOB#7~-~ <br />APN <br />EXP.DATE <br />VALID :3.\~It" <br />STREET ~ <br />AREA <br />TYPE <br />FORMS <br />NOTES <br />REF # <br />CR# <br />DRIVEWAYS: <br />The undersigned hereby applies for p'ermission tp exc~,Gonstruct and/or oth?rwise encro,ach on County Highwa R!9ht-Of-~on <br />the ~side of N ()lL~+I II approximately eet!lie ' <br />of e~-tl'er=-ki ,I£<;OJ ,byperformingthefollowingwork escriptionofwork): <br />Rep l••.c.e <br />Work will commence on or'about __,_J_-~/X-.2 C>I h for approximately days. <br />J,the undersigned,certify that Iam the owner of the 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 />J<o~ <br />Signature of Applicant.Title 3-3 -~oI6 <br />Date