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APPLICATION FOR ENCROACHNENT PERMIT <br />PLEASE PRINT: <br />Date 3/15/2023 <br />To: San Joaquin County <br />Department of Public Works <br />ATT CALIFORNIA/ VALLEY PERMIT DESK <br />(Applicant Name) <br />1445 VAN NESS AVE <br />(IVbiling Address) <br />FRESNO CA 93721 <br />(City, State, Zip Code) <br />559.552.4650 <br />(Area Code -Telephone Number) <br />Sketch (Detailed plans may be submitted) <br />PLEASE SEE ATTACHED DWGS WITH MONUMENT SURVEY, BORE LOCATION, TRAFFIC CONTROL <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 S LEO GIRON DR TO S MANTHEY RD approximately APROX 120OFT feet/mile <br />of , by performing the following work (description of work): <br />BORE UNDER MANTHEY RD APROX 81 FT PLACE 1-4" CONDUIT PLACE APROX 1350FT COPPER CABLE AND STRAND - <br />PLACE 1 TELCO POLE (3) ANCHORS - TRAFFIC CONTROL <br />Work will commence on or about 4/01/23 for approximately 5 DAYS 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 />/lCL2.G �tit./2CGIZG�G? <br />Signature of Appli /ant -Title <br />MICENTP LSHNICE61CLHllCALIPUBSVWKIW STERP6IENCROACHNENT PERMIT APPLICATION 00C (0113) <br />3/15/2023 <br />Date <br />OFFICE USE ONLY <br />JOB # <br />730079 REF # <br />APN <br />CR # <br />EXP.DATE <br />VALID <br />4/1/2023 TO 5/1/2023 DRIVEWAYS: <br />STREETern <br />br. & anan ilFey�� <br />AREA <br />Stockton QUAD WS <br />TYPE <br />(N) Pole, Bore, Aerial Work, (N) Anchors <br />FORMS <br />SS/WW, R-29 <br />NOTES <br />Special Conditions <br />PLEASE SEE ATTACHED DWGS WITH MONUMENT SURVEY, BORE LOCATION, TRAFFIC CONTROL <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 S LEO GIRON DR TO S MANTHEY RD approximately APROX 120OFT feet/mile <br />of , by performing the following work (description of work): <br />BORE UNDER MANTHEY RD APROX 81 FT PLACE 1-4" CONDUIT PLACE APROX 1350FT COPPER CABLE AND STRAND - <br />PLACE 1 TELCO POLE (3) ANCHORS - TRAFFIC CONTROL <br />Work will commence on or about 4/01/23 for approximately 5 DAYS 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 />/lCL2.G �tit./2CGIZG�G? <br />Signature of Appli /ant -Title <br />MICENTP LSHNICE61CLHllCALIPUBSVWKIW STERP6IENCROACHNENT PERMIT APPLICATION 00C (0113) <br />3/15/2023 <br />Date <br />