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APPLICATION FOR ENCROACHMENT PERMIT PLEASE PRINT: Date To: 10/23/19 San Joaquin County Department of Public Works Sydnie Saelee I TAK Communications CA Inc (Applicant Name) 4125 Northgate Blvd (Mailing Address) Sacramento, CA 95834 (City, State, Zip Code) 916-514-9809 (Area Code -Telephone Number) ssaelee@takcommunicationsca.com (Email Address) Sketch (Detailed plans may be submitted) SEE ATTACHED OFFICE USE ONLY JOB II REF# APN CR# EXP.DATE VALID TO STREET AREA QUAD TYPE FORMS NOTES Additional Contact: Luis Ordaz 209-400-7074 luisordaz.cityrise@gmail.com DRIVEWAYS: . . • The undersigned hereby applies for permission to excavate, construct and/or otherwise encroach on County High~ Right-of-Way on tt1e East side of Ideal Pkwy approximately 275' . ~ile North of E Yosemite Ave (Route 120) ________ , by performing the following work (description of work): Tie in at existing vault in landscape and open trench 4' to property address #17H60. Trench to continue on private property. Work will commence on or after _____ 1_2_/2_/_1~9 _______ for approximately _____ 3 _____ 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 tl1e work describ:bg2c:e rules and regulations of San Joaq~~:2::u:ty and subject to inspection and approval. Signature of Applicant -Title Date Y,\FORMS & TEMl'LATES\ENCROACHMEfff PERMIT APPLICATION.doc ((Ja/00)