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APPLICATION FOR ENCROACHMENT PERMIT <br />PLEASE PRINT: <br />Date 1/13/2021 <br />To: San Joaquin County <br />Department of Public Works <br />PG&E - PM 44543506 <br />(Applicant Name) <br />220 Channel St, Stockton, CA <br />(Mailing Address) <br />Stockton, CA, 95202 <br />(City, State, Zip Code) <br />925-701-1564 <br />(Area Code - Telephone Number) <br />gxjl@pge.com <br />(Email Address) <br />Sketch (Detailed plans may be submitted) <br />OFFICE USE ONLY <br />JOB # 730052-6 REF # <br />APN CR # <br />EXP.DATE <br />VALID 2112 021TO DRIVEWAYS: <br />STREETuer�e. <br />AREA btocKton QUAD <br />TYPE <br />FORMS <br />NOTES Special Conditions <br />Crew to call SJ County Inspector at (209) 953-7421 48 to 72 hours before work starts. <br />When calling, crew shall request "rain clearance" for any work during winter months <br />November through March <br />The undersigned hereby applies for permission to excavate, construct and/or otherwise encroach on County Highway Right -of -Way on <br />the SOUTH _sideof Guernsey Ave approximately 110' feet/mile West <br />of S ANTEROS AVE STOCKTON , by performing the following work (description of work): <br />PM 44543506 - PG&E to excavate 4x4 bell hole to conform leak repairs. CCTV may take Dlace. <br />Work will commence on or after 2/12/2021 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 />�� QB2.GL/.csL <br />Signature of Applicant - Title <br />V]FORMS&TENPIATEMENCROACHMEN T PERMIT APPLICATION dov(W&OP <br />1/13/2021 <br />Date <br />