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APPLICATION FOR ENCROACHMENT PERMIT <br />PLEASE PRINT: <br />Date 6/19/23 <br />To: San Joaquin County <br />Department of Public Works <br />Teichert Materials <br />(Applicant Name) <br />3500 American River Dr. <br />(Mailing Address) <br />Sacramento, CA 95864 <br />(City, State, Zip Code) <br />(916) 484-3317 <br />(Area Code - Telephone Number) <br />jsmith@teichert.com <br />(Email Address) <br />may <br />See Attached Plans <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 />6/30/2023 TO 7/30/2023 DRIVEWAYS: <br />Bird Rd. <br />Tracy QUAD SW <br />Driveway encroachment & Replace Asphalt <br />SSAA/VV, R-17 <br />Special Conditions <br />****SEE ATTACHED IMPROVEMENT PLANS**** <br />The undersigned hereby applies for permission to excavate, construct and/or otherwise encroach on County highway right-of-way on <br />the West side of South Bird Road _ approximately 200 feet/w,i & South <br />of Blewett Rd. by performing the following work (description of work): <br />See Attached Plans <br />See Attached Plans <br />See Attached Plans <br />See Attached Plans <br />See Attached Plans <br />Work will commence on or after 06/28/2023 for approximately 1 b 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 />6/19/23 <br />Signat re f Applicant - Title <br />Date <br />