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APPLICATION FOR ENCROACHMENT PERMIT <br />PLEASE PRINT: <br />Date 9/26/23 <br />To: San Joaquin County <br />Department of Public Works <br />Unified Field Services Corporation <br />(Applicant Name) <br />6906 Downing Avenue <br />(Mailing Address) <br />CA 93308 <br />(City, State, Zip Code) <br />(661) 858-8223 <br />(Area Code • Telephone Number) <br />john _starkQo ufsc.us <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 />110005 REF # <br />CR # <br />1n/19/9mTO 10/1 DRIVEWAYS: <br />\/Arous t. ( cati <br />Tracy QUAD SW rt <br />Traffic Control Devices <br />,;,,;AAAA/ <br />Sketch (Detailed plans may be submitted) <br />Will establish traffic control if needed, survey center line of existing CRC buried pipeline, set Above <br />Ground Monitor (AGM) for 1-2 hours, remove AGM, remove traffic control, close out permit. See <br />attached Mapping locations of AGM 010, 020, 030, 040, 050, 060 with shoulder work minor <br />encroachment - TA -6. Work will start 10/12/2023 at 7AM and be completed by 10/13/2023 at 4PM. <br />Traffic Control and Setting of AGMs will on be daylight 7AM to 5PM. <br />See Attached CRC SAN JOAQUIN AGM 010 to AGM 060 for Full Details. <br />The undersigned hereby applies for permission to excavate, construct and/or otherwise encroach on County highway right-of-way on <br />the shoulder side of county easement behind the fog line approximately over CRC Pipeline Q feet/ C mile various <br />of Howard Road, Tract Blvd and Clifton Court Road , by performing the following work (description of work): <br />Will establish traffic control if needed, survey center line of existing CRC buried pipeline, set Above Ground Monitor (AGM) for 1-2 hours, remove AGM, <br />remove traffic control, close out permit. See attached Mapping locations of AGM 010, 020, 030, 040, 050, 060 with shoulderwork minor encroachment- TA -6. <br />Work will start 10/12/2023 at 7AM and be completed by 10/13/2023 at 4PM. Traffic Control and Setting of AGMs will on be daylight 7AM to 5PM <br />Work will commence on or after 10/12/23 for approximately 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 />9/26/23 <br />Sig ure of A Ica 11 le Date <br />