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APPLICATION FOR ENCROACHMENT PERMIT <br />PLEASE PRINT: <br />Date 12/22/2021 <br />To: San Joaquin County <br />Department of Public Works <br />PGE <br />(Applicant Name) <br />3136 Boeing Way <br />(Mailing Address) <br />Stockton, CA 95206 <br />(City, State, Zip Code) <br />209.355.5087 <br />(Area Code - Telephone Number) <br />CYSO@PGE.com <br />(Email Address) <br />may <br />See Attached <br />JOB # <br />APN <br />EXP.DATE <br />VALID <br />STREET <br />STREET <br />AREA <br />TYPE <br />FORMS <br />NOTES <br />OFFICE USE ONLY <br />730052 REF # <br />CR # <br />1/1/2022 TO 6/1/2022 DRIVEWAYS: <br />—7a <br />Stockton QUAD LV <br />Bell Hole <br />SSNW ,, R-29, Trench Cut Policy <br />Special Conditions <br />The undersigned hereby applies for permission to excavate, construct and/or otherwise encroach on County Highwa Right -of -Way on <br />the South side of Paloma Ave approximately 331' eet ile East <br />of Balboa Ave by performing the following work (description of work): <br />PGF to complete restorations TxK depth 8 1 "-19" <br />Work will commence on or after 01/01/2022-06/01/2022 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 />Signature of Applicant - Title <br />V]FORN6&TENPIATEIENCROACHMEN T PERMIT APPLICATION dov(W&OP <br />12/22/21 <br />Date <br />