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APPLICATION FOR ENCROACHMENT PERMIT <br />PLEASE PRINT: <br />Date 8/14/20 <br />To: San Joaquin County <br />Department of Public Works <br />Jeniece Avalos <br />(Applicant Name) <br />5001 Executive Parkway <br />(Mailing Address) <br />San Ramon, CA 94583 <br />(City, State, Zip Code) <br />925-368-0762 <br />jb8236@att.com <br />Sketch (Detailed plans may be submitted) S <br />attached construction drawings witl <br />Traffic Control Plans for complete <br />design. <br />OFFICE USE ONLY <br />JOB # <br />730079-19 REF # <br />APN <br />CR # <br />EXP. DATE <br />12/1/2020 <br />VALID <br />10/28/2020 TO 12/1/2020 <br />STREET <br />East Main St <br />AREA Stockton QUAD ES <br />TYPE Trench, Bores, Bell Holes <br />FORMS SSNWV, R-29 <br />NOTES Special Conditions <br />DRIVEWAYS: <br />The under ned hereby applie for 7eniog#o egavate, construct and/or otherwise encroach on County Highway Right-of-Waon <br />the sou sid� of tas Mai free approximately 85 feet feet/mile east <br />of au a rue ve by performing the following work (description of work): <br />install small cell wireless equipment on AT&T owned wood pole <br />Work will commence on or after <br />for approximately 30 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 Dat <br />r:IFORMSd M WSYFHM=HMENT PERW APPLICATION aoc PN) <br />