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APPLICATION FOR ENCROACHMENT PERMIT <br />PLEASE PRINT: # 8575 <br />Date 4/21/2021 <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 />(City, State, Zip Code) <br />(209)464-8311 <br />(Area Code - Telephone Number) <br />deberhardt@Galwater.com <br />(Email Address) <br />c,. <br />may <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 />Modesto Ave. <br />Stockton QUAD WS <br />Bell Holes - (_2) <br />SS/VWV R-29 Trench Cut Policy <br />Special Conditions <br />W <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 s Modesto Ave approximately 154 feet/mile South <br />of W Church St by performing the following work (description of work): <br />526 S Modesto Ave <br />New 1" Service Install STK0600 <br />2 Cuts - 2'x2' Asphalt (Street) + 4'x4' Dirt <br />will commence on or <br />for approximately <br />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 />YNOMS I WA%AIE CROACNAIFM PEMIITA IWDN da(OBA9) <br />4/21/2021 <br />Date <br />