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APPLICATION FOR ENCROACHMENT PERMIT <br />PLEASE PRINT: <br />Date 03/19/2021 <br />To: San Joaquin County <br />Department of Public Works <br />AT&T/ VCC PERMITS 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 g26977@att.com <br />(Area Code - Telephone Number) <br />Sketch (Detailed plans may be submitted) <br />A COPY OF THE LAYOUT DRAWINGS AND TRAFFIC CONTROL PLAN WILL BE <br />SUBMITTED WITH THIS PERMIT; <br />SEE ATTACHMENTS <br />JOB A01 Z241 <br />The undersigned hereby applies for permission to excavate, construct and/or otherwise encroach on County Highway Right -of -Way on <br />the SOUTH side of SOUTH TUXEDO approximately AT feet/mile <br />of NORTH PERSHING AVE ,byperforming the following work (description ofwork): <br />TRENCH AND PLACE ONE NEW 4' CONDUIT FOR 44FROM AT&T MH 251 TO THE EXISTING AT&T CABINET ON <br />THE CORNER OF S TUXEDO AND N PERSHING <br />Work will commence on or about n4/15/2n91 for approximately 5 F)AYS 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 />Title <br />MICENTP LSHNICE61CLHllCALIPUBSVWKIW STERP6IENCROACHNENT PERMIT APPLICATION 00C (0113) <br />3-19-2021 <br />Date <br />OFFICE USE ONLY <br />JOB # <br />730079 REF # <br />APN <br />CR # <br />EXP. DATE <br />254=21 <br />VALID <br />5r2 <br />0 DRIVEWAYS: <br />STREET <br />Taxedu tva <br />TYPE <br />T1 el iul i,i eet Rep'acemeri <br />FORMS <br />rench CutPolicy <br />NOTES <br />Special Conditions <br />A COPY OF THE LAYOUT DRAWINGS AND TRAFFIC CONTROL PLAN WILL BE <br />SUBMITTED WITH THIS PERMIT; <br />SEE ATTACHMENTS <br />JOB A01 Z241 <br />The undersigned hereby applies for permission to excavate, construct and/or otherwise encroach on County Highway Right -of -Way on <br />the SOUTH side of SOUTH TUXEDO approximately AT feet/mile <br />of NORTH PERSHING AVE ,byperforming the following work (description ofwork): <br />TRENCH AND PLACE ONE NEW 4' CONDUIT FOR 44FROM AT&T MH 251 TO THE EXISTING AT&T CABINET ON <br />THE CORNER OF S TUXEDO AND N PERSHING <br />Work will commence on or about n4/15/2n91 for approximately 5 F)AYS 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 />Title <br />MICENTP LSHNICE61CLHllCALIPUBSVWKIW STERP6IENCROACHNENT PERMIT APPLICATION 00C (0113) <br />3-19-2021 <br />Date <br />