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PLEASE PRINT: <br />Date <br />APPLICATION FOR ENCROACHMENT PERMIT <br />To: San Joaquin County <br />Department of Public Works <br />(Applicant Name) <br />(Mailing Address) <br />?A <br />(City, State, Zip Code) <br />(Area Code - Telephone Number) <br />fa <br />(Email Address) <br />Sketch (Detailed plans may be submitted) <br />JOB # <br />APN <br />EXP. DATE <br />VALID <br />STREET <br />AREAStockton <br />TYPE <br />FORMS <br />NOTES <br />OFFICE USE ONLY <br />REF # PS -2104219 <br />CR # <br />x/28/2023 <br />7/15/2022 TO 2/28/2023 DRIVEWAYS: <br />Qantas Lane, s/o Arch -Airport <br />QUAD SE ' <br />Road closure & b SS road <br />SS/VVVV, R-29, Trenchcut 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 />— rsidta� S Gn approximately .4-€eetlmile <br />by nPrfnrminn the fnlinwinn %Mnr4 (rincrrintinn of ,unrlA. <br />Work will commence on or after for approximately 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 />ature of Applican Date <br />