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APPLICATION FOR ENCROACHMENT PERMIT <br />PLEASE PRINT: <br />Date OFFICE USE ONLY <br />To: San Joaquin County <br />JOB # REF # <br />Department of Public Works APN CR # <br />EXP. DATE <br />VALID TO <br />DRIVEWAYS: <br />(Applicant Name)STREET * <br />AREA QUAD <br />* <br />TYPE * <br />(Mailing Address)FORMS <br />NOTES <br />(City, State, Zip Code) <br />(Area Code - Telephone Number) <br />(Email Address) <br />The undersigned hereby applies for permission to excavate, construct and/or otherwise encroach on County Highway Right-of-Way on <br />the ______________ side of ___________________________________ approximately ___________________ feet/mile _________ <br />of _______________________________________, ____________________, by performing the following work (description of work): <br />Work will commence on or after _____________________________________ for approximately ________________________ 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 />Signature of Applicant - Title Date <br />Y:\FORMS & TEMPLATES\ENCROACHMENT PERMIT APPLICATION.doc (08/08) <br />Sketch (Detailed plans may be submitted) <br />Signature of Applicant -Title <br />PM 74038102 <br /> C-1766 <br />6 h8/ 9/2__________________2/3/20______________________ <br />97 So th <br />yy <br />V S Rd <br />______________d <br />Tracy___________ <br />Install rectifier and deep p well anode, ,&New service to rectifierfor PM 35237200 <br />See scope description for full details <br />Et/Wt <br />gg