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PLEASE PRINT: <br />Date 1/12/24 <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 />APPLICATION FOR ENCROACHMENT PERMIT <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 />1/26/24 TO 4/26/24 DRIVEWAYS: <br />Kingsley Rd. <br />Stockton QUAD <br />Traffic Control Devices <br />SS/VVVV <br />Special Conditions <br />A COPY OF THE TRAFFIC CONTROL PLAN IS SUBMITTED WITH THIS PERMIT; <br />SEE ATTACHMENTS <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 KINGSLEY RD. approximately 1010 @ feet/ Qmile NORTH <br />of SUNNY RD _ , by performing the following work (description of work): <br />TCP NEEDED FOR ONE LANE FIAGGER FOR AERIAL PLACEMENT FROM POLE #P05310 TO POLE RA 05384 ON KINGSLEY RD. ALL JOB RA02PAGB <br />ADDRESS 50W CA 99 <br />Work will commence on or after 1/26/24 for approximately 2 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 />Signature of Applicant - Title <br />Date <br />