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LVA <br />PSC PRINT: APPLICATION FOR ENCROACHMENT PERMIT <br />Date <br />-�-I 23 <br />To: <br />San Joaquin minty <br />r""T"mnent of Public Works <br />PGE <br />(Applicant Name) <br />3136 Bcein9 Way <br />(Mailing Address) <br />Stockto- <br />(City, State, Zip Code) <br />(408)31(408)31-- <br />STDivp (Area Code - Telephone Number) <br />t., com <br />(Email Address) <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 />8/1/2023 TO 2/1/2024 DRIVEWAYS: <br />Valpico Rd. <br />Tracy QUAD SW <br />QPriAl \Nnrk <br />SSM/VV <br />Sketch (Detailed plans may be submitted) <br />Y �4 XT <br />T9 <br />The unders igned hereby applies for permission to excavate, construct and/or otherwise encroach on County highway right-of�y on <br />VlJ side of V/C1 I,.o h! approximately 7.41 6feeUQmile <br />of ► w ws 17uv� by performing the following work (description of work): <br />T6 'T'Fi/1 u✓ � (Yr t^ )c c (ti o a I%d � <br />LtV�yw I <br />Work w 11 wmmence on or after --Z for approximately too days. <br />I, the undersigned, certify the owner of the respective property, or am qualified to represent the owner and agree to do the <br />work described above' accordan with the rules and regulations of San Joaquin County and subject to inspection and approval. <br />%gRatu6ire of Ap cant - Title Date <br />