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APPLICATION FOR ENCROACHMENT PERMIT <br />PLEASE PRINT: <br />Date 6/12/23 <br />To: San Joaquin County <br />Department of Public Works <br />Jake Avila <br />(Applicant Name) <br />2737 Nathan Ave., Suite A <br />(Mailing Address) <br />Modesto, CA 95354 <br />(City, State, Zip Code) <br />(209) 522-3876 <br />(Area Code - Telephone Number) <br />jake@ghipaving.com <br />(Email Address) <br />may <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 # PS -2301725 <br />229-130-30 CR # <br />10/13/23 <br />8/15/23 TO 10/13/23 DRIVEWAYS: <br />Lone Tree Road <br />Escalon QUAD SE <br />Private road connection, driveway <br />SSANW, R-29, Trench Cut Policy <br />Special Conditions <br />Connection of private road (Jellybean Lane) for antiquated subdivision <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 Lone Tree Road approximately 2,350 @ feet/ 0mile West <br />of Henry Road _ , by performing the following work (description of work): <br />Sawcutting approximately 70 lineal feet of existing asphalt edge. Fine grading and installing 3" asphalt over 10" roadbase and <br />re -striping effected fog line to match existing. <br />Work will commence on or after 6/19/23 for approximately 10 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 />6/12/23 <br />Signature of Applicant - Title <br />Date <br />