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APPLICATION FOR ENCROACHMENT PERMIT <br />PLEASE PRINT: <br />Date 7/1/20 <br />To: San Joaquin County <br />Department of Public Works <br />SJC FIRST DISTRICT OFFICE/ CHRIS ROUPPET <br />(Applicant Name) <br />44 N SAN JOAQUIN ST ( BOS) <br />(Mailing Address) <br />STOCKTON, CA 95202 <br />(City, State, Zip Code) <br />(209)468-3113 <br />(Area Code - Telephone Number) <br />CROUPPET@SJGOV.ORG <br />(Email Address) <br />JOB # <br />APN <br />EXR DATE <br />VALID <br />STREETZ1G4t�9 <br />OFFICE USE ONLY <br />// REF # <br />CR # <br />485T, 23 TO 011123, DRIVEWAYS: <br />6 A✓d <br />AREA i5rvakza/V QUAD CC. <br />TYPE TAMP AvAD Ge05a" <br />FORMS <br />NOTES <br />x <br />ADC 46 0.0 tW4APVA1f6 <br />✓is <br />&e 64MST / Z029 o04044 <br />H9 kr MYNK <br />Sketch (Detailed plans may be submitted) <br />F ---JN. AL P A10; A1/E—� <br />IF WIC41 <br />r of " <br />C- W. sorJVWv A Awe- Q <br />W <br />The undersigned hereby applies for permission to excavate, construct and/or otherwise encroach on County highway right-of-way on <br />the SOUTH side of W. ALPINE AVE approximately 300 Q feet/ ()mile <br />of DELEWARE AVE by performing the following work (description of work): <br />BLOCK STREET FOR NATIONAL NIGHT OUT <br />Work will commence on or after <br />a/1/20 <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 />Signature of Applicant - Title Date <br />