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APPLICATION FOR ENCROACHMENT PERMIT <br />PLEASE PRINT: <br />Date 6/23/23 <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 />may <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 />TO DRIVEWAYS: <br />oftat ge e <br />Manteca QUAD <br />Traffic Control Devices <br />SSAMN <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 />thesideof 15896 s CoUage Ave approximately OfeeV ()mile <br />of — — — — — — — — — _, – — — — — _, by performing the following work (description of work): <br />Splice at 1 existing Comcast equipment location in the San Joaquin County ROW <br />Work will commence on or after_ — — — 7/44/23— — — _ for approximately_ — 1 _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 />62323 <br />Signature of licant - Title Date <br />