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APPliCA 110m FOR IEI\!CROACH~JIIENT PIERlViIT <br />PlEASE PRINT; <br />Date '1-7-.2.016 OFFICE USE ONLY <br />To:San Joaquin County <br />.Department of PublicWorks <br />fG/~flit 311,77 803 <br />(Applicant Name) <br />'I{l ~()LJJ et.f;~I\e <br />(Mailing Address) <br />£.'tt>clc--to ".<!)\q ~~()1./ <br />(Cit{.Stile,Zip Code) <br />C204.)37.3-Cflf3::>rxd2eC(le,co"" <br />.(Area Cod!!-Telephone I\lumbe <br />Sketch (Detailed plans may be submitted) <br />JOB#'Bo<:>2_-lp <br />APN <br />EXP.DATE <br />VALID <br />STREET <br />AREA <br />TYPE. <br />FORMS <br />NOTES <br />REF#. <br />CR# <br />DRIVEWAYS: <br />•• <br />.The undersigned hereby applies for permission to excavate,construct andlor otherwise encroach on County Highwa Right-of-Way,on <br />the g side of tJ Ne,w f-"r-t.ftve.-approximately Ii ile ,AJ <br />of ~~";1"~,$-t6'it'Gtptl\;;ibyperfOrmingthefollowingwOrl«(escriptionofwork):R.IA D -f.er,ar-a:tJ lble /5'<'//\leu,oaet Ave.I <br />Work will commence on orabou!7-2.CJ -2..(916'for approximately 2 days. <br />liE NJ){(':""2.0 -.<61(6 .I,the undersigned,certify that I am the owner of the respective property,or am qualified to representthe owner and agreeto do the <br />work described above in accordance with the rules and regulations of san Joaquin.County and subject to inspection and approval. <br />tG..&d Da~,Signature of Applicant-Title <br />/.-7--2.016 <br />.Date <br />,