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APPLICATION FOR ENCROACHMENT PERMIT <br />PLEASE PRINT: <br />Date 2128124 <br />To: San Joaquin County <br />Department of Public Works <br />RoadSafe Traffic Systems <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 />bstah I@ road safetraffic. co m <br />(Email Address) <br />Sketch (Detailed plans may be submitted) <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 />4/1/2024 TO 4/15/2024 DRIVEWAYS: <br />Woodbridge Rd <br />Acampo QUAD <br />Traffic Control Devices <br />SS/WW <br />Special Conditions <br />ioaUn:Oa F <br />60 <br />The undersigned hereby applies for permission to excavate, construct and/or otherwise encroach on County highway right-of-way on <br />the EBI WB side of E Woodbridge Rd. approximately 78 O feet/ Q mile <br />of East St. Acampo, CA , by performing the following work (description of work): <br />Flagging operations and advance warning signage only in the County right of way for off -grade repairs. <br />Work will commence on or after 411124 for approximately 15 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 />2128124 <br />Signature ofApplicant - Title <br />Date <br />