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APPLICATION FOR ENCROACHMENT PERMIT <br />PLEASE PRINT: <br />Date 9/20/23 <br />To: San Joaquin County <br />Department of Public Works <br />Jenna Ortega / SEFNCO Communications <br />(Applicant Name) <br />12687 S Manthey Rd <br />(Mailing Address) <br />Lathrop, CA 95330 <br />(City, State, Zip Code) <br />(209) 817-4566 <br />(Area Code - Telephone Number) <br />JenOrtega@SEFNCO.com <br />(Email Address) <br />Sketch (Detailed plans may be submitted) <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 />1 U12312U23TO12/23/2023 DRIVEWAYS: <br />Tully Rd. <br />Lockeford QUAD NE <br />Traffic Control Devices <br />SS/WW <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 side of 19725 N TULLY RD, approximately _ Q feet/ Q mile <br />of , by performing the following work (description of work): <br />Splice at 1 existing Comcast equipment location in the County of San Joaquin ROW <br />Work will commence on or after 10/23/23 <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 />U6'MV& <br />Signature of A p icant - Title <br />9/20/23 <br />Date <br />