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APPLICATION FOR ENCROACHMENT PERMIT <br />PLEASE PRINT - <br />Date 6/20/2023 <br />To: San Joaquin County <br />Department of Public Works <br />SEFNCO (Comcast) <br />(Applicant Name) <br />12687 S. Manthey Rd. <br />(Mailing Address) <br />Lathrop, CA 95330 <br />(City, State, Zip Code) <br />209-490-3373 <br />(Area Code - Telephone Number) <br />adtrevino@sefnco.com <br />(Email Address) <br />Sketch (Detailed plans may be submitted) <br />See attachments below <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 />7/5/2023 TO 8/5/2023 DRIVEWAYS: <br />Gettysbury PI <br />Stockton QUAD LV <br />Traffic Control Devices <br />SS/WW <br />Special Conditions <br />The undersigned hereby applies for permission to excavate, construct and/or otherwise encroach on County Highway Right -of -Way on <br />the West _ side of Douglas Rd _ approximately 230 _ feet/mile <br />of _ Calhoun PI——3 __, by performing the following work (description of work): <br />Tie into 3 existing Comcast splice case to perform splice. Tie into existing pole and overlash 350' to target pole <br />Work will commence on or after <br />for approximately <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 accordance with the rules and regulations of San Joaquin County and subject to inspection and approval. <br />dK(:A'n44" 6/20/2023 <br />Signature of Applicant - Title Date <br />Y:IFORMS & TEMPLATEMENCROACHMENT PERMIT APPLICATION.doc (08/08) <br />