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APPI-I6A'I1UN FOR ENCROACHMENT PERMIT <br />PI..EASE MIN "l: <br />Date 11 X11 X19 <br />To; San Joaquin County <br />Department of Public Works <br />Sydnie Saelee / TAK Communications CA Inc <br />(Applicant Name) <br />4125 Northgate Blvd <br />(Mailing Address) <br />Sacramento, CA 95834 <br />(City, State, Zip Code) <br />916-514-9809 <br />(Area Code - Telephone Number) <br />ssaelee@takcommunicationsca.com <br />(Email Address) <br />Sketch (Detailed plans may be submitted) <br />SEE ATTACHED <br />OFFICE USE ONLY <br />JOE # (( 000 5 REF # <br />APN CR # <br />EXP. DATE <br />VALID TO _ DRIVEWAYS: <br />STREET ' <br />AREA QUAD <br />TYPE <br />FORMS <br />NOTES <br />Addition��l C;®ntact :Luis Ordaz 209-400-7074 luisordaz. <br />il.ram <br />The undersigned hereby applies for permission to excavate, construct andlor otherwise encroach on County 1.1i him <br />Right -of -Way on <br />the NortYl & Soutn _ Slde Of Douglas Rd approximately 90ee lie east <br />Of Gettysburg PO by performing the following work (description of work); <br />Bore 18011 across Douglas Rd to existing vault in <br />Work will commence on or after 12/9/19 - for approximately <br />3 <br />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 acc�ance with the rules and regulations of San Joaquin County and subject to inspection and approval. <br />11/11/19 <br />Sir,�nature of Applicant -Title <br />Y:IFORIdS & TEIAPlATE51ENCR0ACHIAENT PERMIT APPLICATION.doc (Ofu08) <br />C1ate <br />