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APPLICATION FOR ENCROACHMENT PERMIT <br />PLEASE PRINT: <br />Date 12/29/23 <br />To: San Joaquin County <br />Department of Public Works <br />AT&T /VALLEY PERMIT DESK <br />(Applicant Name) <br />1445 VAN NESS AVE <br />(Mailing Address) <br />FRESNO CA, 93721 <br />(City, State, Zip Code) <br />(559) 285-4894 <br />(Area Code - Telephone Number) <br />g26977@att.com <br />(Email Address) <br />may <br />JOB # <br />APN <br />EXP.DATE <br />VALID <br />STREET <br />AREA <br />TYPE <br />FORMS <br />NOTES <br />OFFICE USE ONLY <br />730079 REF # <br />CR # <br />1/12/2024 TO 4/12/2024 DRIVEWAYS: <br />Chrism an Rd. & 11th St. <br />Tracy QUAD SW <br />Traffic Control Devices <br />SS/WW <br />Special Conditions <br />A COPY OF THE TRAFFIC CONTROL PLAN IS SUBMITTED WITH THIS PERMIT;SEE <br />ATTACHMENTS <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 N CHRISMAN RD. approximately 255 QQ feet/Qmile NORTH <br />of W 11TH ST. by performing the following work (description of work): <br />TCP REQUIRED FOR SHOULDER CLOSURE TO ACCESS MH #168 ON W 11TH ST., LANE SHIFT TO ACCESS SB #316, POLE #23645 ON N CHRISMAN RD. <br />AND RIGHT LANE CLOSURE TO ACCESS MH #120 ON W 11TH ST. <br />AT&T PROJECT #A02R5YH <br />Work will commence on or after 1/12/24 for approximately 4 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 />Parks DI9IhIlY signed by ahem Palm <br />Dene 2023 1229 11 3233-08 00 <br />Signature of Applicant - Title Engineering Administrator <br />12/29/23 <br />Date <br />