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PLEASE PRINT: <br />Date 2128120 <br />APPLICATION FOR ENCROACHMENT PERMIT <br />To: San Joaquin County <br />Department of Public Works <br />AT&T 1 VCC PERMIT DESK <br />(Applicant Name) <br />(Mailing Address) <br />FRESNO, CA 93727 <br />(City, State, Zip Code) <br />559 454 4900 G26977aATT.00M <br />(Area Code - Telephone Number) <br />Sketch (Detailed plans may be submitted) <br />JOB # <br />APN <br />EXP. DATE <br />VALID <br />STREET <br />OFFICE USE ONLY <br />7-2oo 9- 4 REF # <br />CR # <br />La <br />fo / p DRIVEWAYS; <br />Aof{ A <br />AREA <br />TYPE <br />�racr.7$iJ QUAD <br />Ae.&J011- wa)a.k, <br />L.✓ <br />Tc P <br />FORMS <br />NOTES <br />s�wv+J <br />"SGr.4L <br />�e <br />SEE ATTACHED TCP 0E <br />James Jelley <br />(209) 474-4110 <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 6393 Pacific ave approximately feetlmile <br />of , , by performing the following work <br />(description of work <br />POLE 1 6309 VICKSBURG PL AERIAL. STREET CROSSING, POLE 2 6267 N PERSHING AVE AERIAL STREETCROSSING <br />Work will commence on or about 319/20 for approximately _ 10 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 2/28/2020 <br />Administrator <br />Signature of Ap nt - Title Date <br />E%POR SV.WKWAS1ER YSIENCROACHMENT PERMUF APPLICARON DOC (01108) <br />