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APPLICATION FOR ENCROACHMENT PERMIT <br />PLEASE PRINT: <br /> <br />Date OFFICE USE ONLY <br /> <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 /> <br /> <br />(Area Code - Telephone Number) <br /> <br />(Email Address) <br /> <br />Sketch (Detailed plans may be submitted) <br /> <br /> <br /> <br /> <br /> <br /> <br /> <br /> <br /> <br /> <br /> <br /> <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 /> <br /> <br /> <br /> <br />Work will commence on or after _____________________________________ for approximately ________________________ days. <br /> <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 /> <br /> <br /> <br />Signature of Applicant - Title Date <br /> Y:\FORMS & TEMPLATES\ENCROACHMENT PERMIT APPLICATION.doc (08/08) <br />916-514-9809 <br />SEE ATTACHED <br />Sydnie Saelee / TAK Communications CA Inc <br />4125 Northgate Blvd <br />Sacramento, CA 95834 <br />ssaelee@takcommunicationsca.com <br />Additional Contact : Luis Ordaz 209-400-7074 luisordaz.cityrise@gmail.com <br />3 <br />South 155'North <br />Arapaho Way <br />Tie in at existing pedestal at #6148 on Chickasaw Ct & bore 192ft across Chickasaw Way to #14568. <br />Excavate two 3’x5’ bore pits in ROW & install 2” conduit for Comcast service. <br />Chickasaw Ct & Chickasaw Way <br />7/29/20 <br />8/31/20 <br />7/29/20