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APPLICATION FOR ENCROACHMENT PERMIT <br />PLEASE PRINT: <br />Date 8/18/2021 <br />To: San Joaquin County <br />Department of Public Works <br />Pacific Bell Telephone Company dba AT&T, VCC Permit Desk <br />(Applicant Name) <br />5555 E. Olive Ave <br />(Mailing Address) <br />Fresno, CA 93727 <br />(City, State, Zip Code) <br />559-454-4900 <br />(Area Code - Telephone Number) <br />g26977@aft.com <br />(Email Address) <br />may <br />SEE PLANS ATTACHED. <br />JOB # <br />APN <br />EXP.DATE <br />VALID <br />STREET <br />AREA <br />TYPE <br />FORMS <br />NOTES <br />OFFICE USE ONLY <br />730079 REF # <br />CR # <br />9/13/2021 TO 1212021 DRIVEWAYS: <br />Delaware Ave. <br />Stockton QUAD CC <br />Bell Hole, Remove & Replace Concretd Sidewalk <br />SS/WW, R-29, R-5, R-6 <br />Special Conditions <br />The undersigned hereby applies for permission to excavate, construct and/or otherwise encroach on County Highway Right -of -Way on <br />the WEST side of N DELAWARE AVE. approximately 135' feet/mile SOUTH <br />of MICHIGAN AVE , by performing the following work (description of work): <br />DIG AND REPAIR DAMAGED EXISTING CONDUIT C� 2703 N DELAWARE AVE. RESTORE <br />CONCRETE SIDEWALK AND GUTTER. <br />Work will commence on or after 9/13/21 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 above in accordance with the rules and regulations of San Joaquin County and subject to inspection and approval. <br />�2� 10a4Af-/,&z,.�� Engineering Administrator 9-8-2021 <br />Signatur of Applicant - Title Date <br />V]FORMS&TENPIATEIENCROACHMEN T PERMIT APPLICATION dov(W&OP <br />