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APPLICATION FOR ENCROACHMENT PERMIT <br />PLEASE PRINT: <br />Date 2/8/2021 <br />To: San Joaquin County <br />Department of Public Works <br />PGE PM 35123577 <br />(Applicant Name) <br />3136 Boeing Way <br />(Mailing Address) <br />Stockton, CA 95206 <br />(City, State, Zip Code) <br />209-279-3846 <br />(Area Code - Telephone Number) <br />S9P3@PGE.com <br />(Email Address) <br />may <br />OFFICE USE ONLY <br />JOB # REF # <br />APN CR # <br />EXP.DATE <br />VALID TO DRIVEWAYS: <br />STREET <br />AREA QUAD <br />TYPE <br />FORMS <br />NOTES <br />The undersigned hereby applies for permission to excavate, construct and/or otherwise encroach on County Highway Right -of -Way on <br />the West side of Stokes approximately 5 feet/mile North <br />of E Fremont St Stockton , by performing the following work (description of work): <br />PGE to replace damaged crossarm on pole. Traffic Control and PGE to encroach on County ROW <br />Work will commence on or after 3/15/2021 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 />Stacy Police <br />Signature of Applicant - Title <br />V]FORMS&TENPIATEIENCROACHMEN T PERMIT APPLICATION dov(W&OP <br />2/8/2021 <br />Date <br />