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APPLICATION FOR ENCROACHMENT PERMIT Pl.EASE PRINT: Date To: ~ I San Joaquin County Department of Public Works ATT VCC/PERMITS DESK (Applicant Name) 5555 E OLIVE AVE (Mailing Address) FRESNO, CA. 93727 (City, State, Zip Code) 559-454-4900 (Area Code • Telephone Number) OFFICE USE ONLY JOB# REF# APN CR# EXP.DATE VALID TO STREET AREA QUAD TYPE FORMS NOTES Sketch (Detailed plans may be submitted) A COPY OF THE TRAFFIC CONTROL PLANS SUBMITTED WITH THIS PERMIT SEE ATTACHMENTS. A01QL5H 85C Debbie Sneed (559) 739-6646 DRIVEWAYS; * * * The undersigned hereby applies for permission to excavate, construct and/or otherwise encroach on County Highway Right-of-Way on the EAST side of S HARLAN RD approximately 1200 FT feet/mile NORTH of ROTH RD _______ , by performing the following work (description of work): TRAFFIC CONTROL PLAN TO ACCESS POLE P.10850 IN FRONT OF 10762 S HARLAN RD. PLEASE SEE ATTACHED DOCUMENT FOR ADDITIONAL JOB I_OCATION AND DESCRIPTION Work will commence on or about ___ 12_/_20_/_19 _________ for approximately ___ __,_1 _____ days. 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 work described above in accordance with the rules and regulations of San Joaquin County and subject to inspection and approval. M.ICENTRALSERVJCES\CI.ERICALIPUB-SV.W,l'.IASTER.PS\ENCROACHMENT PERMIT APPLICATION.DOC (09/13)