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APPLICATION FOR ENCROACHMENT PERMIT <br />PLEASE PRINT: <br />Date 10/05/2023 <br />To: San Joaquin County <br />Department of Public Works <br />AT&T CALIFORNIA/ VALLEY PERMITS DESK <br />(Applicant Name) <br />1445 VAN NESS AVE <br />(Mailing Address) <br />FRESNO, CA 93721 <br />(City, State, Zip Code) <br />(559)552-4608 G26977@ATT.COM <br />(Area Code - Telephone Number) <br />Sketch (Detailed plans may be submitted) <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 />A COPY OF THE TRAFFIC CONTROL PLAN IS SUBMITTED WITH THIS PERMIT; <br />SEE ATTACHMENTS <br />A02N1J5 <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 LIBERTY RD approximately 17 ee mile EAST <br />of ELLIOTT RD , by performing the following work (-description of work): <br />DIG (3) 4'X4' PITS. BORE & PLACE 541'1-4" DUCT & TRENCH & PLACE 11' 14" DUCT. REMOVE & <br />PERMIT DRAWINGS FOR AT&T JOB# A02N1J5. <br />Work will commence on or about Start: 12/1/2023 - End: 3/1/2024 for approximately _ 10 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 />Engineering <br />${ GgyV .sLybGf Administrator <br />Signature of Applicant - Title <br />MICENTP LSHNICE61CLHllCALIPUBSVWKIW STERP6IENCROACHNENT PERMIT APPLICATION 00C (0113) <br />10/05/2023 <br />Date <br />