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APPLICATION FOR ENCROACHMENT PERMIT <br />PLEASE PRINT: <br />Date 126/22 <br />To: San Joaquin County <br />Department of Public Works <br />West Valley Construction / James Gillette <br />(Applicant Name) <br />2655 E Miner Ave <br />(Mailing Address) <br />Stocldon, CA, 95205 <br />(City, State, Zip Code) <br />(408) 4422402 <br />(Area Code - Telephone Number) <br />;glumea vcccom <br />(Email Address) <br />may <br />See Attached <br />JOB # <br />APN <br />EXP.DATE <br />VALID1/31/2022 <br />STREET <br />AREA <br />TYPE <br />FORMS <br />NOTES <br />OFFICE USE ONLY <br />110005 <br />REF # <br />CR # <br />TO41112022 DRIVEWAYS: <br />an CT t <br />Lockeford QUAD <br />Bei <br />SSNW ,, R-29, Trench Cut Policy <br />Special Conditions <br />The undersigned hereby applies for permission to excavate, construct and/or otherwise encroach on County highway right-of-way on <br />the Est Side side of Noah Iana approximately 185 QQ feet/Qmile Nom <br />of Laird & Lockeford by performing the following work (description of work): <br />Water Leak Repair at 19954 N Ian CI <br />Work will commence on or after 1/31/44 for approximately fi0 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 />es Gillette <br />James Gillet9412.01.28 <br />2.01.28 09:54:22-08'00' 126/22 <br />Signature of Applicant - Title <br />Date <br />