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APPLICATION FOR ENCROACHMENT PERMIT ·PLEASE PRINT: Date To: 11/15/19 San Joaquin County Department of Public Works JOB# APN EXP. DATE OFFICE USE ONLY REF# CR# AT&T/ VCC PERMITS DESK VALID TO (Applicant Name) 5555 E. Olive Ave (Mailing Address) Fresno, CA 93727 (City, State, Zip Code) (559) 454-49.00 g26977@att.co (Area Code -Telephone Number) Sketch (Detailed plans may be submitted) STREET AREA QUAD TYPE FORMS NOTES rr /I OJQJgL/ A COPY OF THE TRAFFIC CONTROL PLAN IS SUBMITTED WITH THIS PERMIT; SEE ATTACHMENTS fl Q.ro/J fY1 o ()r'-( SS~) Lf~l/r 3r;l~ DRIVEWAYS: . . • The undersioned hereby applies for permission to excavate, construct and/or otherwise encroach on County Highway Right-of-Way on the EAST side of N ASHLEY LN approximately 595 ee mile SOUTHEAST of E FOPPIANO LN , _______ , by performing the following work scription of work): ACCESS MANHOLE# 383 TO SPLICE EXISTING FIBER CABLE. PLEASE SEE ATTACHED DOCUMENT FOR OTHER SPECIFIC JOB LOCATION & JOB DESCRIPTION. Work will commence on or about _____________ for approximately ________ days. 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 work described above in accordance witl1 t11e rules and regulations of San Joaquin County and subject to inspection and approval. CA/y;'A,/Ct'/'",IV? I 'I frr:c.... ~r I Date M:\CENTRALSERVICES\CLERICALIPUB-SV.WKV~ASTER.l'S\ENCROACHMElff PERMIT APPLICATION.DOC (03/13)