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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 <br />DRIVEWAYS: <br />(Applicant Name)STREET * <br />AREA QUAD <br />* <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 />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 />JOB# <br />@takcommunicationsca.com <br />Additional Contact : 209- cityrise .com <br />SEE ATTACHED <br />TAK Communications CA Inc <br />Sacramento, CA 95834 <br />4125 Northgate Blvd <br />916-514-9873 <br />04/04/2024 <br />North E. Blossom Ct.0 West <br />CA-12/ N Hwy-88 <br />482613 <br />05/13/2024 2 days <br />04/04/2024