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APPLICATION FOR ENCROACHMENT PERMIT <br />PLEASE PRINT: <br />Date OFFICE USE ONLY <br />To: San Joaquin County JOB # REF # <br />Department of Public Works APN CR # <br />EXP. DATE <br />VALID TO DRIVEWAYS: <br />(Applicant Name) STREET * <br />AREA QUAD * <br />TYPE * <br />(Mailing Address) FORMS <br />NOTES <br />(City, State, Zip Code) <br />(Area Code - Telephone Number) <br />(Email Address) <br />Sketch (Detailed plans may be submitted) <br />The undersigned hereby applies for permission to excavate, construct and/or otherwise encroach on County Highway Right-of-Way on <br />the ______________ side of ___________________________________ approximately ___________________ feet/mile _________ <br />of _______________________________________, ____________________, by performing the following work (description of work): <br />Signature of Applicant - Title Date <br />Y:\FORMS & TEMPLATES\ENCROACHMENT PERMIT APPLICATION.doc (08/08) <br />PGE <br />3136 Boeing Way <br />Stockton, CA 95206 <br />209-279-3846 <br />S9P3@PGE.com <br />10/06/21 <br />See attached <br />West S Modesto Ave 66'South <br />Church St <br />LOC1: PGE to replace pole, transformer, meter guy wire, pull service cable-overhead work <br />LOC2:PGE to pull triplex service cable <br />Work will commence on or after _________01/03/22_____________________ for approximately ___1____ 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 />PM 35249515 <br />Time will be from 7:30AM-5:30PM <br />10/06/21