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IPlEASE IPRH\lf: <br />Date (J-?-<1 -2016 OFFICE USE ONLY <br />DRIVEWAYS: <br />REF # <br />,. <br />JOB# <br />APN <br />EXP,DATE -_--J-~4_L,fJJ'~~~__ <br />VAliD <br />STREET <br />,~REA <br />TYPE <br />FORMS <br />NOTES <br />PGdE PIJV,3Io/;zt.'J(17 <br />I/-\illllicalit Nmne) <br />To:San Joaquin COunty <br />'Department of Public Works <br />J.-.lo Ltv We-$.+L(;\.-~"e... <br />(lhl"nliIT1g l\lIiilre5s) <br />$t"e,k --¥/j "'-cl'\-G1 Y2.tl '{'(Gnty,SI'le,Znp Colle) <br />hI!~)??7?-~eN :3<.p'xch ef9e:.&it' <br />L..(Area Go!Jle •feiellhllrne IIllIDlber) <br />Sketch (Detailed plans may be submitted) <br />See 5-,ke'tcA <br />2)L '"e,-tl(,A:~0 v\s.u.J 0 ~~ke (/~ <br />.The undersigned hereby applies for .(Iermission to excavate,construct and/or otherwise encroach on County Highwa~Right-of-\I)Iay on <br />the K side of 1/1 Mt!u~Ave~.approximately ;2.0"',7~D.Ileo f6J1mlle ..s <br />of (!€"in"b~,eel',G~<::«/0(/\,by performing the foliating work (description of work):, <br />«~~~~3 =r::;;?Y~)}/25)Q<;j;it~P'e <br />.~~,"".!1C{1;;..~'_. <br />Work will commence on or about 7-!B -:::2..016 for approximately 'Z.days. <br />(;5'.1j)H -:ti)-.26 t6"' <br />I,the undersigned,certify that I am the owner ofthe respective property,oram 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 />~{D;;~ <br />Signature of Applicallt ..Title <br />b ,-:::!."i'-~i;)1-6- <br />Do!e <br />tt\CElffilAl.'lEflV!CESlClF.RlCAt,IPUB.SV.\'IK'MIlSIERPS\EllCROACHMBH PEfw;rr APfliCATIOIiJJOG (m'113)