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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/DQH3136Bi :HVW :HVW <br />Way/DQH/DQH <br />6WRFNWRQ&$Stockton, 6WRFNWRQ6WRFNWRQ CA&$&$95204 <br />   <br />209 857 0181       <br />VS]#SJHFRPS#SJVS]#SJHFRPS#SJWAT8@PGE.COMVS]#SJHFRPVS]#SJHFRP <br />PM 31643189 <br />4/27/23 <br />4/27/23 <br />6 h/2 /23__________________/2 /23____________________ <br />CO dh &C________________Cl b ld <br />Stockton <br />Replacep cross arm on existingg pole. p NO GROUND DISTURBANCE WILL TAKE PLACE