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APPLICATION FOR ENCROACHMENT PERMIT <br />PLEASE PRINT: <br />Date OFFICE USE ONLY <br />To: San Joaquin County JOB # REF # <br />Department of Public Works APN CR # <br />EXP. DATE <br />VALID TO DRIVEWAYS: <br />(Applicant Name) STREET * <br />AREA QUAD * <br />TYPE * <br />(Mailing Address) FORMS <br />NOTES <br />(City, State, Zip Code) <br />(Area Code - Telephone Number) <br />(Email Address) <br />Sketch (Detailed plans may be submitted) <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 />07/01/2021 20 <br />NO DIRT WORK WILL BE INVOLVED. ALL PLACING/SPLICING WILL TAKE PLACE IN EXISTING AT&T FACILITIES, <br />MANHOLES, POLES, ETC. <br />05/13/2021EngineeringAdministrator