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PLEASE PRINT: <br />Date 5/1/23 <br />To: San Joaquin County <br />Department of Public Works <br />LLC <br />(Applicant Name) <br />PO Box 1221 <br />(Mailing Address) <br />CA 95366 <br />APPLICATION FOR ENCROACHMENT PERMIT <br />(City, State, Zip Code) <br />(209) 596-1816 <br />(Area Code - Telephone Number) <br />brock@impacthomes.net <br />(Email Address) <br />may <br />See attached drawings <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 />6/20/2023 TO 7/1/2023 DRIVEWAYS: <br />Micke Grove Rd. <br />Lodi QUAD NW <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 Toru side of Micke Grove Rd approximately 30 @ feet/ 0mile <br />of 11250 N Micke Grove Rd Lodi, CA by performing the following work (description of work): <br />Joint Trench crossing on N. Micke Grove rd, Lodi, CA. Power only NO Gas. <br />Attached is a copy of the traffic control plan as well as a copy of PG&E compsite. <br />We will need 1 day to open trenches and place pipes & 1 day to patch paving. <br />Work will commence on or after 6/26/23 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 />Brock Rose LY.212'. ^mm '°'^-"" .....- <br />Signature of Applicant - Title <br />5/1/23 <br />Date <br />