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APPLICATION FOR ENCROACHMENT PERMIT <br />PLEASE PRINT: # 8579 <br />Date 4/22/2021 <br />To: San Joaquin County <br />Department of Public Works <br />California Water Service Company <br />(Applicant Name) <br />1602 E Lafayette St <br />(Mailing Address) <br />Stockton, Ca 95205 <br />State, Zip Code) <br />(209)464-8311 <br />(Area Code - Telephone Number) <br />deberhardt@calwater.com <br />(Email Address) <br />Sketch (Detailed plans may be submitted) <br />See attached <br />JOB# <br />APN <br />EXP. DATE <br />VALID <br />STREET <br />AREA <br />TYPE <br />FORMS <br />NOTES <br />OFFICE USE ONLY <br />730077 REF# <br />CR # <br />4/22/2021 To 7/1/2021 DRIVEWAYS: <br />Mendocino Ave. <br />Stockton QUAD CC <br />Bell Holes (3) ' <br />SSAM/V, R-29, R-5, R-6, 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 West side of W Mendocino Ave approximately 33 feettmile south <br />of Modoc Ave , by performing the following work (description of work): <br />2940 Modoc Ave (On W Mendocino Ave) <br />1" Service Reolacement cTunnnn <br />3 Cuts - 4'x4'& 4'x7'+ 4'x4' Concrete Sidewalk <br />Work will commence on or after 4/22/2021 for approximately 60 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 />David Eberhardt Jr- Operations Clerk <br />Signature of Applicant - Title <br />Y:"KIS& TFAI%g1EMMOA HMW PMATMKIGNONft �8) <br />4/22/2021 <br />Date <br />