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APPLICATION FOR ENCROACHMENT PERMIT <br />PLEASE PRINT: <br />Date <br />To: San Joaquin County <br />Department of Public Works <br />RoadSafe Traffic Systems; Brittany Bechtold <br />(Applicant Name) <br />PO Box 1270 <br />(Mailing Address) <br />Verdi, NV 89439 <br />(City, State, Zip Code) <br />(775) 622-2950 <br />(Area Code - Telephone Number) <br />bsta hl@roadsafetraffic.com <br />(Email Address) <br />Sketch (Detailed plans may be submitted) <br />Please see attached TCP <br />JOB # <br />APN <br />EXP. DATE <br />VALID <br />STREET <br />OFFICE USE ONLY <br />110005 REF # <br />CR # <br />7/24/2023 TO 8/1/2023 DRIVEWAYS: <br />Roth Rd. <br />AREA <br />TYPE <br />Manteca QUAD SW <br />Traffic Control Devices <br />FORMS <br />NOTES <br />The undersigned hereby applies for permission to excavate, construct and/or otherwise encroach on County highway right-of-way on <br />the EBS WB side of E Roth Rd. approximately 180 (�) feet/ Q mile <br />of A st. Manteca , by performing the following work (description of work): <br />Railroad Repairs requiring flagging operations only for the sake of Railroad Tie replacements. <br />Work will commence on or after 1 i 2M 12S for approximately t 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 />Project Coordinator 1 k`, ,La <br />Signature 6f Applicant - Title bate <br />