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APPLICATION FOR ENCROACHMENT PERMIT <br />PLEASE PRINT: <br />Date 3/30/22 <br />To: San Joaquin County <br />Department of Public Works <br />Pacific Gas & Electric- Candice Lacceth <br />(Applicant Name) <br />1524 N. Carpenter Rd <br />(Mailing Address) <br />Modesto, CA 95351 <br />(City, State, Zip Code) <br />(925) 303 9471 <br />(Area Code - Telephone Number) <br />C0L5@pgecom / STDivpgepennits@pge corn <br />(Email Address) <br />Sketch (Detailed plans may be submitted) <br />PM 35322450 <br />JOB # <br />APN <br />EXP.DATE <br />VALID <br />STREET <br />AREA <br />TYPE <br />FORMS <br />NOTES <br />OFFICE USE ONLY <br />730052 REF # <br />CR # <br />6/17/2022 TO 12/15/2022 DRIVEWAYS: <br />Willow St. <br />French Camp QUAD SW <br />Trench <br />SS/WVV, R-29, Trench Cut Policy <br />Special Conditions <br />The undersigned hereby applies for permission to excavate, construct and/or otherwise encroach on County highway right-of-way on <br />the –_North_ side of — — _s_ willow s_ _ _ _approximately – —44/— _Qfeet/ Qmile_ welt <br />of ESeventh S[ French camp by performing the following work (description of work): <br />Excavate to replace existing gas service. Restoration to follow. <br />Work will commence on or after_ — — — 6/17/22 — — — _ for approximately_ — 1eo---- 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 />3/3022 <br />ignature of %applicant <br />Date <br />