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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 /> <br />(City, State, Zip Code) <br />(Area Code - Telephone Number) <br /> <br />(Email Address) <br />Sketch (Detailed plans may be submitted) <br /> <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 />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 />10/3/22 <br />10/3/22 <br />SEE ATTACHED <br />Additional Contact : Luis Ordaz 209-400-7074 luisordaz.cityrise@gmail.com <br />TAK Communications CA Inc <br />2 <br />Sacramento, CA 95834 <br />4125 Northgate Blvd <br />954-818-6202 <br />csaeteurn@takcommunicationsca.com <br />South E Kettleman Ln 850 East <br />Hoerl Rd <br />Tie in at existing pole on E Kettleman Ln. Overlash 674ft of new cable across 4 existing poles on E Kettleman Ln. <br />11/1/22 <br />JOB# JB1192948 <br />LO