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APPLICATION FOR ENCROACHMENT PERMIT <br />PLEASE PRINT: <br />Date 1/22/24 <br />To: San Joaquin County <br />Department of Public Works <br />VCC 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 />Sketch (Detailed plans may be submitted) <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 />1/22/24 TO 2/22/24 DRIVEWAYS: <br />Ashley Ln. <br />Stockton QUAD <br />Emergency Pole Replacement <br />SS/WW <br />Special Conditions <br />After the fact for a emergency pole replacement <br />A02QW8K <br />The undersigned hereby applies for permission to excavate, construct and/or otherwise encroach on County highway right-of-way on <br />the RIGHT side of E ASHLEYN LN. approximately 115 Q feet/ © mile EAST <br />of ALHAMBRA AVE. CA , by performing the following work (description of work): <br />POLE #6025; REMOVE OLD POLE, PLACE EXTENTION ARM, TRANSFER 4 AERIAL LEEDS, RE -LASH 200' NEAR 6037 E ASHLEY LN. <br />After the fact for a emergency pole replacement <br />Work will commence on or after <br />for approximately <br />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 />1/22124 <br />Signature of Applicant - Title Date <br />