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APPLICATION FOR ENCROACHMENT PERMIT <br />PLEASE PRINT: <br />Date March 22, 2021 <br />To: San Joaquin County <br />Department of Public Works <br />Jeniece Avalos <br />(Applicant Name) <br />5001 Executive Parkway <br />(Mailing Address) <br />San Ramon, CA 94583 <br />(City, State, Zip Code) <br />925-368-0762 <br />(Area Code - Telephone Number) <br />jb8236@att.com (Email Address) <br />Sketch (Detailed plans may be submitted) <br />JOB # <br />APN <br />EXP. DATE <br />VALID <br />STREET <br />OFFICE USE ONLY <br />110005 REF # <br />CR # <br />12/1/2021 TO 2/11/2022 DRIVEWAYS: <br />Cardinal Ave. <br />AREA <br />TYPE <br />Stockton QUAD ES <br />Bore, Trench, Pole Replacement <br />FORMS <br />NOTES <br />SS/WW, R-29 <br />Special Conditions <br />See attached construction drawings with traffic control plans for complete design <br />The undersigned hereby applies for permission to excavate, construct and/or otherwise encroach on County Highway Right -of -Way on <br />the east side of South Cardinal Avenue approximately pp y 685 feet/mile south <br />of Ardelle Avenue . by performing the following work (description of work). <br />install small cell wireless equipment on AT&T owned 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 describeNove in accordance with the rules and regulations of San Joaquin County and subject to inspection and approval. <br />Signatu <br />Y IFORMS 6 <br />Applicant - Title <br />T+MIT APPLICATION doc (08108) <br />A I V'-� � P, A <br />Date <br />