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APPLICATION FOR ENCROACHMENT PERMIT <br />PLEASE PRINT: <br />Date 12/31/21 <br />To: San Joaquin County <br />Department of Public Works <br />Candice Laccetti - PG&E <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 />C6L5@pge.com / STDivpgepermits@pge.com <br />(Email Address) <br />Sketch (Detailed plans may be submitted) <br />PM 35297712 <br />JOB # <br />APN <br />EXP. DATE <br />VALI D <br />STREET <br />AREA <br />TYPE <br />FORMS <br />NOTES <br />OFFICE USE ONLY <br />730052 REF # <br />CR # <br />3/1/2022 TO 9/1/2022 DRIVEWAYS: <br />Adelbert Ave. <br />Stockton QUAD ES <br />Trench <br />SS/WW, R-29, Trench Cut Policy <br />Special Conditions <br />The undersinned herehv andies for nermission to excavate_ construct and/or otherwise encroach on County highway right-of-way on <br />the '625 Adelbert Ave _ approximately 45 � feet/ Q mile North <br />Of Horner Stockton , by performing the following work (description of work): <br />Trench to install new gas service. CCTV may take place. Restoration to follow. <br />Work will commence on or after 3/1/22 for approximately 180 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 />12/31/21 <br />Signature of Applicant - Title <br />Date <br />