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APPLICATION FOR ENCROACHMENT PERMIT <br />PLEASE PRINT: <br />Date <br />To: San Joaquin County <br />Department of Public Works <br />PGE - JESSE ZAMORA - PM45069320 <br />(Applicant Name) <br />3136 Boeing Way <br />(Mailing Address) <br />Stockton, CA 95206 <br />(City, State, Zip Code) <br />209-687-5031 <br />(Area Code - Telephone Number) <br />jlzi@PGE.com <br />(Email Address) <br />may <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 />4/8/2022 TO 10/15/2022 DRIVEWAYS: <br />Terrace Dr. <br />Stockton QUAD M <br />Bell Hole <br />SSAVW, 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 <br />on the side of Terrace Dr <br />approximately 51 <br />feet _South _ <br />of Franceen Ln I Stockton/Morada , by performing the following work (description of work): <br />PGE to excavate 44 bellhole to repair gas leak, cctv pre/post inspection may take place - restoration to follow <br />Work will commence on or after 4/8/2022 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 />!±! _ ij' Ila, PERMIT FACILITATOR <br />gnature 6f Applicant - Title <br />V]FORN6&TENPIATEIENCROACHMEN T PERMIT APPLICATION dov(W&OP <br />21112022 <br />Date <br />