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M:\CENTRALSERVICES\CLERICAL\PUB-SV.WK\MASTER.PS\ENCROACHMENT PERMIT APPLICATION.DOC (09/13) <br />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 />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 about _____________________________________ 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 />AT&T CALIFORNIA / VCC PERMITS DESK <br />1445 VAN NESS AVE <br />Fresno, CA 93721 <br />(559)552-4608 <br />EAST SIDE CORRAL HOLLOW RD <br />ACCESS (1) POLE IN COUNTY R.O.W. FOR FIBER PLACEMENT <br />W LINNE RD. <br />35 <br />12/30/2021 <br />TCP SIGNAGE WILL BE PLACED IN COUNTY R.O.W. FOR ADDITIONALWORK DONE IN CITY OF TRACY <br />1/12/2022 5 <br />SEE ATTACHED TCP DRAWING FOR THE JOB ATT #A028DPQ <br />SOUTH <br />EngineeringAdministrator 01/04/2022 <br />A028DPQ