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APPLICATION FOR ENCROACHMENT PERMIT <br /> PLEASE PRINT: <br /> Date August 31, 2010 OFFICE USE ONLY <br /> To: San Joaquin County JOB# REF# __ <br /> Department of Public Works APN CR;= <br /> EXP.DATE <br /> Wally Sandelin, City of Lodi, Public Works Department VALID / ® TO Z DRIVEWAYS: <br /> (Applicant Name) STREET _ <br /> AREA QUAD -- - <br /> 221 West Pine Street _ TYPE <br /> (Mailing Address) FORMS w:,a <br /> Lodi, CA 95240 NOTES --- <br /> (City,State,Zip Code) <br /> (209)333-6706 -- -" <br /> (Area Code-Telephone Number) <br /> Sketch(Detailed plans may be submitted) <br /> See attached Plans and speciFications for details. <br /> The undersigned hereby applies for permission to excavate, construct and/or otherwise encroach on County Highway Right-of-Way on <br /> the east side of State Route 99 approximately 500 feet <br /> on Harney Lane between the East Frontage Road and Beckman Road by performing the following work(description of work): <br /> -Excavate existing pavement and facilities <br /> -Widen Harney Lane between East Frontage Road and Beckman Road <br /> -Install traffic signal and roadway lighting at the intersection of Harney Lane and East Frontage Road <br /> Work will commence on or about November 2010-January 2011 for approximately 50 working days. <br /> I, 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 /> SigAture of Applicant-Title Date <br /> [4'UB WAFWSIER PMEWCRCA(;HW!IT A WAI IAPPUCAT IUII D'vC fol;CB) <br />