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APPLICATION FOR ENCROACHMENT PERMIT <br />PLEASE PRINT: <br />Date 14- S - zb <br />To: San Joaquin County <br />Deparbri�Public Works <br />(Applicant Name) \\ <br />(Hellin/ ,� dndress) <br />s..Zyy' 4 <br />(City, State, Zip Code) <br />Za`) - Z IZ FSS 53 <br />(Area Code - Telephone Num �) <br />STni✓Pr�P," T� <br />(Email Address) <br />JOB# <br />APN <br />EXP. DATE <br />VALID <br />STREET <br />OFFICE USE ONLY <br />730052 REF# <br />CR # <br />4/10/2022 TO 10/15/2022 DRIVEWAYS: <br />Cotta Rd. ' <br />AREA <br />TYPE <br />FORMS <br />NOTES <br />Lodi <br />Pole Repair <br />SSAA W <br />Spec al Cond <br />QUAD NW ' <br />' <br />tons <br />Sketch (Detailed plans may be submitted) (1 <br />Wim- tJ �qtiv b <br />The underss hereby applies for ppp�nnission to excavate, construct and/or otherwise encroach on County Highway Right -of -Way on <br />the side of Gam- c.+4 -,K l approximately S \ t feetfmile -& <br />of 17 � - k) by performing the following work (description of work): <br />Work will commence on or after It -10 - 22 for approximately days. <br />I, the undersigned, certify that I amf� swn respective property, or am qualified to represent the owner and agree to do the <br />work described above in a0005lein6e wdh� and regulations of San Joaquin County and subject to inspection and approval. <br />• nmA <br />