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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 <br />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 - VALLEY PERMIT DESK <br />1445 VAN NESS AVE <br />FRESNO, CA 93721 <br />(559) 552-4608 g26977@att.com <br />12/17/2021 <br />A COPY OF THE TRAFFIC CONTROL PLAN IS SUBMITTED WITH THIS PERMIT; <br />SEE ATTACHMENTS <br />NORTH GRANT LINE RD <br />ACCESS MANHOLE#1075 TO SPLICE EXISTING FIBER CABLE. <br />6TH ST <br />135 EAST <br />THE ASSOCIATED TCP IS SUBMITTED WITH THIS PERMIT FOR AT&T JOB# A028V66. <br />E/S EL RANCHO RD, 60' S/O CALIFORNIA AVE, ACCESS POLE#22138 TO SPLICE EXISTING CABLE. <br />N/S CALIFORNIA, 3,820' N/W EL RANCHO RD ACCESS SPLICEBOX#1073 TO SPLICE EXISTING CABLE. <br />1/4/2022 3 <br />A028V66 <br />12/20/2021EngineeringAdministrator