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APPLICATION FOR ENCROACHMENT PERMIT <br />PLEASE PRINT: <br />Date 03/18/2024 <br />To: San Joaquin County <br />Department of Public Works <br />TAK Communications CA Inc <br />(Applicant Name) <br />4125 Northgate Blvd <br />(Mailing Address) <br />Sacramento, CA 95834 <br />(City, State, Zip Code) <br />916-514-9873 <br />(Area Code - Telephone Number) <br />permifting@takcommunicationsca.com <br />(Email Address) <br />Sketch (Detailed plans may be submitted) <br />SEE ATTACHED <br />JOB # <br />APN <br />EXP.DATE <br />VALID <br />STREET <br />AREA <br />TYPE <br />FORMS <br />NOTES <br />110005 <br />4/20/2024 <br />Broadway Ave. <br />Stockton <br />Aenal Work <br />ssa <br />special conditions <br />OFFICE USE ONLY <br />REF # <br />CR # <br />TO 5/20/2024 DRIVEWAYS: <br />QUAD <br />Additional Contact : Ray Jones 209-227-2538 permit@cityrisesafety.com <br />The undersigned hereby applies for permission to excavate, construct and/or otherwise encroach on County Highway Right -of -Way on <br />the East & West side of N Broadway Ave approximately 1 feet i1 South <br />of Waterloo Rd , by performing the following work (description of work): <br />TIE IN AT EXISTING POLE ON N BROADWAY AVE AND OVERLASH 558FT OF NEW CABLE ACROSS 5 EXISTING <br />POLES ON N BROADWAY AVE. <br />Job# JB1587612 <br />Work will commence on or after 04/29/2024 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 A plicant - Title <br />YdORMS&TENPIATEIENCROACHMEN T PERMIT APPLICATION dov(WAS) <br />03/18/2024 <br />Date <br />