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APPLICATION FOR ENCROACHMENT PERMIT <br />PLEASE PRINT: <br />Date 09/05/19 <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.com <br />(Area Code - Telephone Number) <br />Sketch (Detailed plans may be submitted) <br />OFFICE USE ONLY <br />JOB # REF # <br />APN CR # <br />EXP. DATE <br />VALID TO DRIVEWAYS: <br />STREET <br />AREA 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 undersianed hereby applies for permission to excavate, construct and/or otherwise encroach on County Highway Right -of -Way on <br />the SOUTH side of W LINNE RD approximately 15 ee mile EAST <br />of S LEHMAN RD, , by performing the following work ( scription of work): <br />AERIAL FIBER PLACEMENT INVOLVING (9) POLES INVOLVING (2) AERIAL STREET CROSSINGS <br />OVER S LEHMAN RD & S KASSON RD. <br />PLEASE SEE ATTACHED DOCUMENT FOR OTHER SPECIFC JOB LOCATIONS &DESCRIPTION. <br />Work will commence on or about <br />7 days. <br />10/4//19-12/4119 <br />for approximately <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 ofCapplicant -"Title <br />M'\CEIJTRALSERVICES\CLERICALIPNRSV.4VMMASTER.PS\ENCRCACN}RENT PERMIT APPLICATION.DOC (09/l9) <br />9/19/2019 <br />Date <br />