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APPLICATION FOR ENCROACHMENT PERMIT <br />PLEASE PRINT: �S <br />Date � /.-?—/d o.21/ <br />To: San Joaquin County <br />P@bPPS��tYu �,+) car) <br />Rbber -� C4 -{-res c <br />(Applicant Name) <br />(Mailing Address) <br />1-04W.,., CA 95110 <br />(City, State, Zip Code) <br />-20 - 4/79-8763 <br />Code - T lephone Number) <br />4 65e wmsn- Com <br />(Email Address) <br />Sketch (Detailed plans may be submitted) <br />The undersigned hereby applies for permission to <br />the DU h side of 11 Ve Lia A <br />of <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 />2/10/2024 TO 4/10/2024 DRIVEWAYS: <br />Live Oak Rd <br />Lodi QUAD <br />Trench (dirt shoulder) <br />SS/WW, R-29 <br />Special Conditions <br />L • AW Aw <br />Work will commence on or after <br />and/or otherwise encroach on County Highwa Right -of -Way on <br />approximately fee ile <br />by performing the following work ( escription of work): <br />for approximately <br />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 />..a_2 -I <br />Signature of App nt - it a Date <br />Y:IFORMS & TEMPLATESIENCROACHMENT PERMIT APPLICATION Ex (08/08) <br />