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2016 JU1\27 P;'1 3:li3 <br />,,"'e_,•-,\'/0 i:'\'Si);.:'eT,;'Cl'I LD~.\'v '1'1 r~n <br />Date 6-2.7-.2CP/6 OFFICE USE ONLY <br />To:San Joaquin County <br />.Department of Public Works <br />e&iE A"I 3Il83~'t1f <br />IApplficmil Name) <br />!.jOLlo aJesi'~flle. <br />(MaiHfii1!j Aokllre,s) <br />5>-t II ek -i:iH'1,61t <1:;'<"'""~O if <br />(Cfily,Stille[Zip Coole). <br />f2.OC('1 s7?"-'it.!5 Z(j\rea Cotie •I eleplioHie !\l1l111~er) <br />Sketch (Detailed plans may be submitted) <br />JOB # <br />APN <br />EXP.DATE <br />VALID. <br />STREET <br />AREA <br />TYPE <br />FORMS <br />NOTES <br />DRIVEWAYS: <br />.The undersigned hereby applies forperm.iSSion to ex.cavate,con.'struct and/or otherwise encroach on County High~.Right-of-Wpy on <br />theW side of f1J I :J<'l.J'l:5:To t\e Pd epproximately 'iG:~miie ~~__ <br />of &ra G(;Ia j)\olk ~t,L/1J D:::L ,by performing the following work (description of work):, <br />Work will commence on or about 7 -Ie -2.0 t K for approximately 2.-days, <br />Er,J'D Il-;20-20tl .'. <br />I,the undersigned,certify that I am the owner of the respective property,or ani qualified to represent tile 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 an,d approval. <br />MuJL DrAA~SigrmMe of Applicant.Tilie <br />~t\CENTRAlSERV1a:SlCiERlC.'L1J'Ufl.SV.WK1MASTffiPSIE1ICROACHlI.a~TPERMrr APf'LICATtON.tlOG (0!:113) <br />6 -~(-;:<6/tf <br />!lale