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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 /> <br />(City, State, Zip Code) <br /> <br />(Area Code - Telephone Number) <br /> <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 />Signature of Applicant - Title Date <br />Y:\FORMS & TEMPLATES\ENCROACHMENT PERMIT APPLICATION.doc (08/08) <br /> 1/25/2021 <br />Qualtek Wireless LLC - Elliott Froissart <br />1200 Del Paso Rd, Suite 150 <br />Sacramento, CA 95834 <br />916-472-1076 <br />efroissart@qualtekwireless.com <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 />Work will commence on or after ______2/1/22_______________________________ for approximately ________________________ days. 30