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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 />of _______________________________________, ____________________, by performing the following work (description of work): <br />Work will commence on or after _____________________________________ for approximately ________________________ 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 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 />6/30/2021 <br />PM 35254769 <br />The undersigned hereby applies for permission to excavate, construct and/or otherwise encroach on County Highway Right-of-Way on <br />the _____Both_________ side of ___________Grant Line Rd________________________ approximately _____200ft______________ feet/mile ___West______ 6th St Tracy <br />PGE to trench 70ft. install riser and electric service. CCTV pre/post inspection, restoration to follow <br />8/4/2021 5 <br />6/30/2021