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APPLICATION FOR ENCROACHMENT PERMIT <br />PLEASE PRINT: <br />Date 08/06/2021 <br />To: San Joaquin County <br />Department of Public Works <br />SEFNCO (Comcast) <br />(Applicant Name) <br />12687 S. Manthey Rd. <br />(Mailing Address) <br />CA 95330 <br />(City, State, Zip Code) <br />209-278-8159 <br />(Area Code - Telephone Number) <br />pheusler@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 />9/6/2021 TO 10/15/2021 DRIVEWAYS: <br />Fairoaks Rd. <br />Tracy QUAD <br />Bell hole <br />SSAA/W, R-29 <br />Special Conditions <br />The undersigned hereby applies for permission to excavate, construct and/or otherwise encroach on County Highwa Right -of -Way on <br />the North side of Fairoaks Rd approximately 260 feet ile East <br />of Julie Lynne circle , by performing the following work ( escription of work): <br />Place new power supply and riser up to tie into PG&E transformer. <br />Work will commence on or after 09/06/2021 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 />Q$/(1F/7(171 <br />5 a ure of Applicant - Title Date <br />V]FORMS&TENPIATEIENCROACHMEN T PERMIT APPLICATION dov(W&OP <br />