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APPLICATION FOR ENCROACHMENT PERMIT <br />PLEASE PRINT: <br />Date 12/8/21 <br />To: San Joaquin County <br />Department of Public Works <br />Candice Laccetti-PG&E <br />Name) <br />1524N Carpenter Rd <br />(Mailing Address) <br />Modesto CA 95351 <br />(City, State, Zip Code) <br />(925) 303 9471 <br />(Area Code - Telephone Number) <br />C0L5@pge com / STDivpgepennitspAirge corn <br />(Email Address) <br />Sketch (Detailed plans may be submitted) <br />PM 35291204 <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 />2/7/2022 TO 8/15/2022 DRIVEWAYS: <br />Alpine Rd. <br />Lodi QUAD NE <br />Bell Hole, Trench <br />SS/WVV, 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 on <br />the eas<— side of — — Iv_Alp ine Rd_ _ _ _approximately— seas— Tfeet/©mile_ Boom <br />of — — — E. victor Rd_ _ _ _ _ _ Lod_ _ by performing the following work (description of work): <br />Excavate to relocate ods service. Restoration to follow. <br />Work will commence on or after_ — — — ?/r/?? — — — _for approximately6Monm5 <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 />21zj�nA / n YY7-* <br />Signature of Applicant - Title <br />12/8/21 <br />Date <br />