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APPLICATION FOR ENCROACHMENT PERMIT <br /> PLEASE PRINT: <br /> Date 11-4-12 OFFICE USE ONLY <br /> To: San Joaquin County JOB# ?D(I%'j' REF# <br /> Department of Public Works APN CR# <br /> AT&T CA C/O: JOHN KOZINA EXP.DATE <br /> ho DRIVEWAYS: <br /> (Applicant Name) STREET <br /> AREA d QUAD <br /> 2300 E Eight Mile Rd #100 TYPE /0 <br /> (Mailing Address) FORMS _x�J <br /> 2 016, <br /> NOTES <br /> Stockton, CA 95210 <br /> (City,State,Zip Code) <br /> 209-474-4254 <br /> (Area Code-Telephone Number) <br /> Sketch(Detailed plans may be submitted) <br /> REFER TO ATTACHED PLANS - <br /> AT&T PROJECT 8737906, Drawing 1-2 of 2 <br /> The undersigned hereby applies for permission to excavate,construct and/or otherwise encroach on County Highway Right-of-Way on <br /> the South & Westside of Peltier Rd & Frontage Rd approximately 280 feet feet/mile East <br /> of Highway 99by performing the following work(description of work): <br /> Trench & place 810' feet of 2-1.25" innerduct, 47 feet of 1-4" <br /> conduit and one (1) 4'x W' fiber optic vault in dirt from pole <br /> P4578 to 22364 N 99 Frontage Rd. <br /> Work will commence on or about 11-26-12 for approximately 5 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 ab a in accordance with the rules and regulations of San Joaquin County and subject to inspection and approval. <br /> Pr-Lett� r 1 I .c> I� <br /> i ture of Applic t Title Date <br /> E.%PUB-SV.Y STE NCROACHMENTPERMITAPPLICATION.DOC (01108) <br />