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M:\CENTRALSERVICES\CLERICAL\PUB-SV.WK\MASTER.PS\ENCROACHMENT PERMIT APPLICATION.DOC (09/13) <br />APPLICATION FOR ENCROACHMENT PERMIT <br />PLEASE PRINT: <br />Date OFFICE USE ONLY <br />To: San Joaquin County <br />JOB # REF # <br />Department of Public Works APN CR # <br />EXP. DATE <br />VALID TO <br />DRIVEWAYS: <br />(Applicant Name)STREET * <br />AREA QUAD <br />* <br />TYPE * <br />(Mailing Address)FORMS <br />NOTES <br />(City, State, Zip Code) <br />(Area Code - Telephone Number) <br />Sketch (Detailed plans may be submitted) <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 />Work will commence on or about _____________________________________ for approximately ________________________ 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 Date <br />02/09/2023 <br />02/09/2023 <br />Signature of Applicacacacacacan <br />Engineering <br />Administrator <br />AT&T CALIFORNIA/VALLEY PERMITS DESK <br />1445 VAN NESS AVE <br />FRESNO, CA 93721 <br />(559)552-4608 G26977@ATT.COM <br />THE ASSOCIATED TCP IS SUBMITTED WITH THIS PERMIT. SEE THE ATTACHED PERMIT <br />DIG (1) 4 4 PIT TO LOCATE & INTERCEPT E ISTING 1-4 ST ED D CT, DIG (1) 4 6 PIT <br />EST ILCO RD 297 NORT <br />PEPSI PL <br />DRA INGS FOR AT&T O A02 SC4. <br />TO PLACE NE 3 5 SPLICE O , TRENC & PLACE 7 1-4 D CT.