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APPLICATION FOR ENCROACHMENT PERMIT <br />PLEASE PRINT: <br />Date 04/25/23 <br />To: San Joaquin County <br />Department of Public Works <br />Marc Wiederhold - CHC Consulting <br />(Applicant Name) <br />3011 Triad PI. <br />(Mailing Address) <br />Livermore, CA 94551 <br />(City, State, Zip Code) <br />(Area Code - Telephone Number) <br />CHC-Permitting-6Qchccnnsulting cnm <br />(Email Address) <br />may <br />See attached <br />OFFICE USE ONLY <br />JOB # REF # <br />APN CR # <br />EXP.DATE <br />VALID TO DRIVEWAYS: <br />STREET <br />AREA QUAD <br />TYPE <br />FORMS <br />NOTES <br />The undersigned hereby applies for permission to excavate, construct and/or otherwise encroach on County Highway Right -of -Way on <br />the side of approximately feet/mile <br />of , by performing the following work (description of work): <br />Access Pole #1 for splicing and perform traffic control as needed <br />Location: Stockton - Beighle St north of 10th St <br />Work will commence on or after 06/05/23 for approximately 1 Dav 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 />2" Permitting for Comcast <br />Signature of Applicant - Title <br />V]FORMS&TENPIATEIENCROACHMEN T PERMIT APPLICATION dov(W&OP <br />04/25/23 <br />Date <br />