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APPLICATION FOR ENCROACHMENT PERMIT <br />PLEASE PRINT: <br />Date 1/18/2022 <br />To: San Joaquin County <br />Department of Public Works <br />PG&E - PM 44544511 <br />(Applicant Name) <br />220 Channel St, Stockton, CA <br />(Mailing Address) <br />Stockton, CA, 95202 <br />(City, State, Zip Code) <br />925-701-1564 <br />(Area Code - Telephone Number) <br />gxjl@pge.com <br />(Email Address) <br />Sketch (Detailed plans may be submitted) <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 />3/21/2022 TO 9/1/2022 DRIVEWAYS: <br />Mendocino Ave. <br />Stockton QUAD CC <br />Bell Hole <br />SSAVW, R-29, R-5, R-6, Trench Cut Policy <br />Special Conditions <br />Crew to call SJ County Inspector at (209) 953-7421 48 to 72 hours before work starts. <br />When calling, crew shall request "rain clearance" for any work during winter months <br />November through March <br />The undersigned hereby applies for permission to excavate, construct and/or otherwise encroach on County Highway Right -of -Way on <br />the SOUTH sideof W MENDOCINO AVE approximately 310' feet/mile WEST <br />of KI RK AVE I STOCKTON , by performing the following work (description of work): <br />4'X4' BELL HOLE FOR UTILITY GAS REPAIR WORK. CCTV MAY TAKE PLACE <br />Work will commence on or after for approximately 2 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 />�eerL QB2G�CsL 1/18/2022 <br />Signature of Applicant - Title V Date <br />V]FORMS&TENPIATEIENCROACHMEN T PERMIT APPLICATION dov(W&OP <br />