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APPLICATION FOR ENCROACHMENT PERMIT <br /> PLEASE PRINT: <br /> Date 10/27/2015 OFFICE USE ONLY <br /> To: San Joaquin County JOB# "-7GJ REF# <br /> Department of Public Works APN CR# <br /> EXP.DATE <br /> AT&T / Sherry Parks (Permits Desk) VALID I2J57- S TO �s ( DRIVEWAYS: <br /> (Applicant Name) STREET cW5 <br /> AREA QUAD _ <br /> 5555 E. Olive Ave TYPE <br /> (Mailing Address) FORMS S OQ'�jl e vl 1 j,��� �r,c <br /> NOTES <br /> Fresno, CA 93727 <br /> (City,State,Zip Code) <br /> (559) 454-4900 g26977@att. corr <br /> (Area Code-Telephone Number) <br /> Sketch (Detailed plans may be submitted) <br /> Please see the attached drawings. <br /> A 00 9 Yc__, � <br /> The undersigned hereby applies for permission to excavate,construct and/or otherwise encroach on County Highway Right-of-Way on <br /> the W side of Mathews Rd approximately 55 feet <br /> of S Delivery Rd pp y feet/mile <br /> , by performing the following work(description of work): <br /> Place 86 ' 1-4" duct via trench, Place 3 ' 1-4" riser duct. Traffic control <br /> plan is in place for trenching. Please see the attached drawings . <br /> Work will commence on or about 11/0 3/2 015 for approximately 5 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 /> Y1 J] rlC-e-n � <br /> MA 'i — Aca m) n; sf-rnL- <br /> r Signatur f Applicant-Title <br /> Date <br /> M.ICENTRALSERVICESICLERICALPUB-SV.WKIMASTER.PSIENCROACHMENT PERMIT APPLICATION.DOC (09/13) <br />