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APPLICATION FOR ENCROACHMENT PERMIT <br />PLEASE PRINT: <br />Date 11-2-2020 <br />To: San Joaquin County <br />Department of Public Works <br />Learn Backhoe & <br />(Applicant Name) <br />4907 Griffin Rd <br />(Mailing Address) <br />Ca,95326 <br />(City, State, Zip Code) <br />209-531-3895 <br />(Area Code - Telephone Number) <br />Rory@ lea mbackhoe. com <br />(Email Address) <br />Sketch (Detailed plans may be <br />See Attached Documents <br />JOB # <br />APN <br />EXP.DATE <br />VALID <br />STREET <br />AREA <br />TYPE <br />FORMS <br />NOTES <br />OFFICE USE ONLY <br />110005 REF # <br />CR # <br />02/01/2021 <br />11/16/2020 TO DRIVEWAYS: <br />ouu `1— <br />French Camp QUAD SW <br />Trench <br />SSANVV, 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 N/E side of 4th Street approximately 1Oft feet/mile N/W <br />of Ash St , by performing the following work (description of work): <br />We will be crossing 4th street to provide a gas service for the new construction O oinq on at 7707 S Ash St. It will consist of a 12" wide <br />trench to lay in a 1" HDPE poly line. Saw cut and remove pavement and will patch back with new pavement. <br />Work will commence on or after 11-16-2020 for approximately 2 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 />/e&1u <br />Signature &Applicant - Title <br />V]FORMS&TENPIATEIENCROACHMEN T PERMIT APPLICATION dov(W&OP <br />11-2-2020 <br />Date <br />