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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 /> <br /> <br /> <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 />NORTH EAST <br />SEE PERMIT TCP DRAWINGS FOR MORE DETAILS. <br />E. EIGHT MILE RD.1532' <br />WEST LANE <br />TO NEW POLE ALREADY PLACED BY PG&E. <br />JOINT POLE, TO REMOVE OLD POLE, PLACE GROUND BED, RESTORE GROUND AREA & TRANSFER FACILITIES <br />AT&T JOB# A023FQP REQUIRES SHOULDER CLOSURE ON E. EIGHT MILE RD. FOR AT&T, IN COORDINATION WITH PG&E <br />9/11/23 2 <br />8/30/23 <br />8/30/2023Engineering <br />AdministratorBrian E. Schultz <br />A023FQP