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APPLICATION FOR ENCROACHMENT PERMIT <br />PLEASE PRINT: <br />Date <br />12/30/2021 <br />To: San Joaquin County <br />Department of Public Works <br />AT&T CALIFORNIA - VALLEY PERMIT DESK <br />(Applicant Name) <br />1445 VAN NESS AVE <br />(Mailing Address) <br />FRESNO, CA 93721 <br />(City, State, Zip Code) <br />(559) 552-4608 g26977@att.com <br />(Area Code - Telephone Number) <br />Sketch (Detailed plans may be submitted) <br />A COPY OF THE TRAFFIC CONTROL PLAN IS SUBMITTED WITH THIS PERMIT; <br />SEE ATTACHMENTS <br />A028R7C <br />The undersigned hereby applies for permission to excavate, construct and/or otherwise encroach on County Highway Right-of-Wa on <br />the SOUTH side of W LARCH RD approximately 1,322 ee mile WEST <br />of N TRACY BLVD , by performing the following work (-description of work): <br />DIG (1) 2'X2' PIT TO PLACE (1) NEW 30FT CLASS 4 POLE IN DIRT. <br />ESTIMATED START: 1/03/22 ESTIMATED COMPLETE: 4/03/22 DURATION: 3 DAYS <br />THE ASSOCIATED TCP IS SUBMITTED WITH PERMIT. PLEASE SEE THE ATTACHED PERMIT <br />DRAWINGS FOR AT&T JOB# A028R7C. <br />Work will commence on or about 11319099 for approximately <br />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 />Engineering <br />'s cd44&- Administrator <br />Signature ofApplican5ritle <br />MICENTP LSHNICE61CLHllCALIPUBSVWKIW STERP6IENCROACHNENT PERMIT APPLICATION 00C (0113) <br />12/30/2021 <br />Date <br />OFFICE USE ONLY <br />JOB # <br />730079 <br />REF # <br />APN <br />CR # <br />EXP.DATE <br />VALID <br />TO <br />5/15/2022 DRIVEWAYS: <br />STREET <br />Larch Rd. <br />AREA <br />Tracy QUAD <br />SW <br />TYPE <br />(N) Pole Install <br />FORMS <br />SS/VVyV <br />NOTES <br />Special Conditions <br />A COPY OF THE TRAFFIC CONTROL PLAN IS SUBMITTED WITH THIS PERMIT; <br />SEE ATTACHMENTS <br />A028R7C <br />The undersigned hereby applies for permission to excavate, construct and/or otherwise encroach on County Highway Right-of-Wa on <br />the SOUTH side of W LARCH RD approximately 1,322 ee mile WEST <br />of N TRACY BLVD , by performing the following work (-description of work): <br />DIG (1) 2'X2' PIT TO PLACE (1) NEW 30FT CLASS 4 POLE IN DIRT. <br />ESTIMATED START: 1/03/22 ESTIMATED COMPLETE: 4/03/22 DURATION: 3 DAYS <br />THE ASSOCIATED TCP IS SUBMITTED WITH PERMIT. PLEASE SEE THE ATTACHED PERMIT <br />DRAWINGS FOR AT&T JOB# A028R7C. <br />Work will commence on or about 11319099 for approximately <br />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 />Engineering <br />'s cd44&- Administrator <br />Signature ofApplican5ritle <br />MICENTP LSHNICE61CLHllCALIPUBSVWKIW STERP6IENCROACHNENT PERMIT APPLICATION 00C (0113) <br />12/30/2021 <br />Date <br />