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APPLICATION FOR ENCROACHMENT PERMIT <br />PLEASE PRINT: <br />Date OFFICE USE ONLY <br />To: San Joaquin County JOB # REF # <br />Department of Public Works APN CR # <br />EXP. DATE <br />VALID TO DRIVEWAYS: <br />STREET * <br />AREA QUAD * <br />TYPE * <br />FORMS <br />NOTES <br />(Email Address) <br />Sketch (Detailed plans may be submitted) <br />The undersigned hereby applies for permission to excavate, construct and/or otherwise encroach on County Highway Right-of-Way on <br />the ______________ side of ___________________________________ approximately ___________________ feet/mile _________ <br />of _______________________________________, ____________________, by performing the following work (description of work): <br />Signature of Applicant - Title Date <br />Y:\FORMS & TEMPLATES\ENCROACHMENT PERMIT APPLICATION.doc (08/08) <br />PGE <br />(Applicant Name) <br />(Mailing Address) <br />(City, State, Zip Code) <br />(Area Code - Telephone Number) <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 />3136 BOEING WAY <br />STOCKTON, CA 95206 <br />209-687-5031 <br />j1zi@pge.com <br />PGE to trench appx 20', 3' from Edge of pavement, and install SCADA eqipment, cctv pre/post inspection may take place <br />APPX 3 DAYS OF WORK <br />3/11/2022 <br />PM 31386414 -- OCW LINNE RD TRACY BL TRACY <br />South W Linne Rd 2150'___EastS Tracy Blvd Tracy <br />3/11/2022 <br />Work will commence on or after ___________3/11/2022________________________ for approximately ___________180_____________ days.