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t' <br />OFFICE USE ONLY <br />To:S@nJoaquin County <br />.Department of Public WOIt$ <br />I':)f.A f::,!V-j,,= <br />5 t,t'c-k TC"Yi!!e.A q~~<;)~:~ <br />ICiay,SitOi~e,Zili1l G!1role) <br />Sketch (Detailed plans may be submitted) <br />tee.41:'+"i ehed <br />JOB It 1stx>-SJ.rr.:., <br />API\] <br />EXP.DATE <br />VALID <br />STREET <br />AREA <br />TYPE <br />FORMS <br />NOTES <br />REFit <br />CR# <br />DRIVEWAYS: <br />.~ <br />The undersigned'hereby applies for permission to excava e,construct and/or otherwise encroach on County Higd:'~i9ht-of-Way on <br />the .N side of approximately I 'l 2.0 e He '1.0 <br />of A M VI(aO"'\,by performing the following work (description of work):, <br />Work will commence on or about for approximately days. <br />J,the undersigned,certify that I am 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~Signature of Applicant -Title 3-..2-~O 16 <br />Date