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APPLICATION FOR ENCROACHMENT PERMIT <br />PLEASE PRINT: <br />Date 3/3/2021 <br />To: San Joaquin County <br />Department of Public Works <br />PGE Jesse Martinez PM35223619 <br />(Applicant Name) <br />3753 E California <br />(Mailing Address) <br />Fresno Ca 93715 <br />(City, State, Zip Code) <br />559-558-6690 <br />rea Code - Telephone Number) <br />J032 pge.com <br />(Email Address) <br />may <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 />o 20120211 511 512921 <br />�TO DRIVEWAYS: <br />rO v9 <br />toc ton QUAD <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 East side of N. Oro Ave approximately 134 FT feet/mile South <br />of �T by performing the following work (description of work): <br />PGE o excavate 4'1 bellhole to deactvate gas line <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 />ignature of Applicant - Title <br />V]FORMS&TENPIATEIENCROACHMEN T PERMIT APPLICATION dov(W&OP <br />3/3/2021 <br />Date <br />