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APPLICATION FOR ENCROACHMENT PERMIT <br />PLEASE PRINT: <br />Date I-1-20 <br />To: San Joaquin County <br />Department of Public Works <br />S ..hvie� /✓3'ervi reo%' LLG <br />(Applicant Name) <br />(Mailing Address) <br />Gh _ 9 53:d <br />(City, State, Zip Code) <br />coq-Sav-EiSso�+ <br />(Area Code -Telephone Number) <br />&,,� CJ M _ LOM <br />(Email <br />JOS# <br />APN <br />EXP.DATE <br />VALID <br />STREET <br />OFFICE USE ONLY <br />110005 REF/ <br />CR # <br />3/3/2024 TO 3/5/2024 DRIVEWAYS: <br />Multiple I orations <br />AREA <br />TYPE <br />QUAD ' <br />Temp Road Closure <br />FORMS <br />NOTES <br />Sper d Council <br />Sketch (Detailed plans may be submitted) <br />any- 4,,k RPa✓l aJ A -,N,4 <br />• Sr,Jffi;ca- rifr.-il <br />The undersigned hereby applies for permission to excavate, construct and/or otherwise encroach on Cchlgh light-ol-way on <br />the side of approxlmately �IeeV��nlle <br />of by performing the following work (destrlptlon of work): <br />Lone Tree Rd., Ven Allen Rd., Avena Rd., Carrolton Rd., Dodds Rd., and Murphy Rd. at BNSF Railroad crossings <br />commence on or <br />for approximately <br />days. <br />I, the undersigned, car* 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 Joaquln County and subject to Inspection and approval. <br />� — " /-/-20 YH <br />Signature - Tole Date <br />