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APPLICATION FOR ENCROACHMENT PERMIT <br />PLEASE PRINT: <br />Date 3/23/23 <br />To: San Joaquin County <br />Department of Public Works <br />TAK Communications CA Inc <br />(Applicant Name) <br />4125 Northgate Blvd <br />(Mailing Address) <br />Sacramento, CA 95834 <br />(City, State, Zip Code) <br />916-956-3689 <br />(Area Code - Telephone Number) <br />skite@takcommunicationsca.com <br />(Email Address) <br />Sketch (Detailed plans may be submitted) <br />SEE ATTACHED <br />JOB # <br />APN <br />EXP.DATE <br />VALID <br />STREET <br />AREA <br />TYPE <br />FORMS <br />NOTES <br />OFFICE USE ONLY <br />110005 REF # <br />CR # <br />TO DRIVEWAYS: <br />e�177 <br />Lodi QUAD NW <br />Bore, Bore Pits <br />SS WW <br />t3pecial Uonclitions <br />Additional Contact : Luis Ordaz 209-400-7074 Iuisordaz.cityriseC�gmail.com <br />The undersigned hereby applies for permission to excavate, construct and/or otherwise encroach on County Highway Right -of -Way on <br />the south side of Tehama Dr approximately 320 eet ile South <br />of E Kristen ct , by performing the following work (description of work): <br />Tie in at existing pedestal at #808 on Tehama Dr. Bore 113ft on Tehama Dr and place new vault at #13625. Install 2" conduit for conEcast service. <br />JOB# 549685 <br />Work will commence on or after 5/8/23 for approximately 2 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 />yo <br />Signature of Applicant - Title <br />V]FORMS&TENPIATEIENCROACHMEN T PERMIT APPLICATION dov(W&OP <br />3/23/23 <br />Date <br />