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APPLICATION FOR ENCROACHMENT PERMIT <br />PLEASE PRINT: <br />Date 08/31/2023 <br />To: San Joaquin County <br />Department of Public Works <br />California Water Service Company <br />(Applicant Name) <br />1602 E Lafayette St <br />(Mailing Address) <br />Stockton, Ca 95205 <br />(City, State, Zip Code) <br />(209)547-7934 <br />(Area Code - Telephone Number) <br />ahenson@calwater.com <br />(Email Address) <br />Sketch (Detailed plans may be submitted) <br />See attached <br />#8708 <br />JOB # <br />APN <br />EXP. DATE <br />VALID <br />STREET <br />AREA <br />TYPE <br />FORMS <br />NOTES <br />OFFICE USE ONLY <br />730052 REF # <br />CR # <br />—C� Bl d 1 112012023 DRIVEWAYS: <br />Stockton QUAD <br />_13—eITTFole— <br />SSMM, R-29, Tiench CUL 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 South side of Country Club Blvd approximately 250 feet/mile West <br />of marine Ave , by performing the following work (description of work): <br />1" Service R <br />1 Cut -3'XT <br />STK0600 <br />Work will commence on or after 08/31/2023 for approximately 60 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 />Antoinette Henson - Field Service Representative 08/31/2023 <br />Signature of Applicant - Title Date <br />Y:WWS SR PUME CR0ILHMEM PEWIT APPIICARM.d¢ OHS) <br />