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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 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 />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 /> <br />3* ( <br />:HVW/DQH <br />6WRFNWRQ&$ <br />   <br />VS]#SJHFRP <br />Sketch (Detailed plans may be submitted) <br />&UHZWRFDOO6-&RXQW\,QVSHFWRUDW  WRKRXUVEEHIRUHZRUNVWDUWV <br />:KHQFDOOLQJFUHZVKDOOUHTXHVWUDLQFOHDUDQFHIRUDQ\ZRUNGXULQJZLQWHUPRQWKV <br />1RYHPEHUUWKURXJKK0DUFK <br />Signature of Applicant -Title <br />:HVW/DQH1524NCarpenter:HVW /DQH:HVW /DQH <br />Rd <br />6WRFNWRQ&$Modesto, 6WRFNWRQ6WRFNWRQ CA&$&$95351 <br />   <br />209 857 0181       <br />p <br />VS]#SJHFRP <br />p <br />VS #SJH FR <br />WAT8@PGE.COMVS]#SJHFRPVS]#SJHFRP <br />PM 45729043 <br />4/26/23 <br />4/26/23 <br />6 h/2 /23_________________/2 /23__________________ <br />175'West <br />W E lid A <br />Nth <br />Stockton <br />maintenance work on existingg pole. p NO GROUND DISTURBANCE WILL TAKE PLACE