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APPLICATION FOR ENCROACHMENT PERMIT <br />PLEASE PRINT: <br />Date 05/01 /19 <br />To: San Joaquin County <br />Department of Public Works <br />AT&T / VCC PERMITS DESK <br />(Applicant Name) <br />5555 E. Olive Ave <br />(Mailing Address) <br />Fresno, CA 93727 <br />(City, State, Zip Code) <br />(559) 454-4900 g26977@att.con <br />(Area Code -Telephone Number) <br />Sketch (Detailed plans may be submitted) <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 andlor otherwise encroach on County Highway Right-of-WaY on <br />the SOUTH side of W SCHULTE RD approximately 1 252 ee mile EAST <br />of BUD LYONS WAY by performing the following work scription of work): <br />DIG (2)41X41 PITS IN DIRT & PLACE 8'14" DUCT VIA BORE, <br />PLEASE SEE THE ATTACHED DOC <br />DESCRIPTIONS. <br />Work will commence on or about <br />ENT FOR OTHESPECIFIC JOB <br />R LOCATIONS &JOB <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 />Sign <br />re of Applicant •Title <br />�►�c�i v���.ri tr1 <br />M:ICENTRALSERVICESICLERICALIPUB-SV.WKIMASTER.PSIENCROACHMENT PERMIT APPLICATION.DOC (09/13) <br />Date <br />OFFICE USE ONLY <br />JOB # <br />7� REF # <br />APN <br />CR # <br />EXP. DATE <br />VALID <br />TO DRIVEWAYS: <br />STREET <br />AREA <br />QUAD <br />TYPE <br />FORMS <br />NOTES <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 andlor otherwise encroach on County Highway Right-of-WaY on <br />the SOUTH side of W SCHULTE RD approximately 1 252 ee mile EAST <br />of BUD LYONS WAY by performing the following work scription of work): <br />DIG (2)41X41 PITS IN DIRT & PLACE 8'14" DUCT VIA BORE, <br />PLEASE SEE THE ATTACHED DOC <br />DESCRIPTIONS. <br />Work will commence on or about <br />ENT FOR OTHESPECIFIC JOB <br />R LOCATIONS &JOB <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 />Sign <br />re of Applicant •Title <br />�►�c�i v���.ri tr1 <br />M:ICENTRALSERVICESICLERICALIPUB-SV.WKIMASTER.PSIENCROACHMENT PERMIT APPLICATION.DOC (09/13) <br />Date <br />