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PLEASE PRINT: <br />APPLICATION FOR ENCROACHMENT PERMIT <br />Date 10/23/2019 <br />To: San Joaquin County <br />Department of Public Works <br />City of Lodi <br />(Applicant Name) <br />221 W Pine St <br />(Mailing Address) <br />Lodi, CA 95240 <br />(City, State, Zip Code) <br />209-333-6706 <br />(Area Code - Telephone Number) <br />abernardino@lodi.gov <br />(Email Address) <br />Sketch (Detailed plans may be submitted) <br />Please see detailed plans attached <br />JOB # <br />APN <br />EXP. DATE <br />VALID <br />STREET <br />OFFICE USE ONLY <br />j/ ppps REF # <br />CR # <br />3 i CO 415 A6 DRIVEWAYS: <br />1-d, r * <br />AREA <br />TYPEntCHl <br />FORMS <br />NOTES <br />Gob/ QUAD MIA) <br />Nla <br />�r9L L�dN D <br />The undersigned hereby applies for permission to excavate, construct and/or otherwise encroach on County Highway Right -of -Way on <br />the north side of Harney Lane approximately 40 feet/mile west <br />of Lower Sacramento Road by performing the following work (description of work): <br />Installing approximately 600 feet of 10" water main in Harney Lane from N. Extension Road to 75' west of <br />Springer Lane (County Limits). <br />A domestic water service will be provided to Henderson School, 13451 N. Extension Road, Lodi,CA <br />95242.This includes trenching, backfilling, boring, and paving <br />Work will commence on or after <br />1/25/2019 <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 />1%141 WC 0/1 01 <br />Signature of Applicant - Title Date <br />Y:WORMS 8 TEMPLATESENCROACHME14T PERMIT APPLICATION.Aac (08108) <br />