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APPLICATION FOR ENCROACHMENT PERMIT <br />PLEASE PRINT: <br />Date 09/25/19 <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 />A01 PATY <br />A COPY OF THE TRAFFIC CONTROL PLAN IS SUBMI I TED WITH THIS PERMIT; <br />SEE ATTACHMENTS <br />The undersianed hereby applies for permission to excavate, construct and/or otherwise encroach on County Highway Right -of -Way on <br />the SOUTH side of WATERLOO RD approximately 40 ee mile WEST <br />of N F ST by performing the following work ( scription of work): <br />ACCESS MANHOLE# 324 (STREET) TO SPLICE EXISTING FIBER CABLE, <br />PLEASE SEE THE ATTACHED DOCUMENT FOR OTHER SPECIFIC JOB LOCATIONS &JOB <br />DESCRIPTIONS. <br />Work will commence on or about <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 />ature of <br />licant •Title <br />Engineering Administrator 9-26-2019 <br />M:ICEMRALSERVICESICLERICALIPUB-SV.WKUMSTER.PSIENCRCACHMENT PERMIT APPLICATIDN.BOC (09119) <br />Date <br />OFFICE USE ONLY <br />JOB# <br />/� <br />730 V 7t? 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 />A01 PATY <br />A COPY OF THE TRAFFIC CONTROL PLAN IS SUBMI I TED WITH THIS PERMIT; <br />SEE ATTACHMENTS <br />The undersianed hereby applies for permission to excavate, construct and/or otherwise encroach on County Highway Right -of -Way on <br />the SOUTH side of WATERLOO RD approximately 40 ee mile WEST <br />of N F ST by performing the following work ( scription of work): <br />ACCESS MANHOLE# 324 (STREET) TO SPLICE EXISTING FIBER CABLE, <br />PLEASE SEE THE ATTACHED DOCUMENT FOR OTHER SPECIFIC JOB LOCATIONS &JOB <br />DESCRIPTIONS. <br />Work will commence on or about <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 />ature of <br />licant •Title <br />Engineering Administrator 9-26-2019 <br />M:ICEMRALSERVICESICLERICALIPUB-SV.WKUMSTER.PSIENCRCACHMENT PERMIT APPLICATIDN.BOC (09119) <br />Date <br />