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APPLICATION FOR ENCROACHMENT PERMIT <br />PLEASE PRINT: <br />Date 3/9/20 <br />To: San Joaquin County <br />Department of Public Works <br />PG&E PM 44176454 <br />(Applicant Name) <br />1524 N Carpenter Rd <br />(Mailing Address) <br />Modesto, CA 95351 <br />(City, State, Zip Code) <br />209-857-0181 <br />(Area Code •Telephone Number) <br />WAT8@PGE.COM <br />(Email Address) <br />Sketch (Detailed plans may be submitted) <br />JOB # <br />APN <br />EXP. DATE <br />VALID <br />STREET <br />AREA <br />TYPE <br />FORMS <br />NOTES <br />OFFICE USE ONLY <br />rj ws, a_ 4 REF # <br />CR # <br />4 iS 30 <br />'6124' 20 TO 4 fS zo DRIVEWAYS: <br />" F to gf. <br />45y�7y QUAD AIS <br />ojf64 fNcLE <br />p/nd � 24 �IAU,CK e&r` 414 <br />T A dAA40i 00S" <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 East side of N FST i#�e approximately 263' ee mile South <br />of 4411w4 loss AW I Stockton by performing the following work ((desc(ption of work): <br />Restore pavement after emergency gas leak (4x4) <br />Work will commence on or after 3/25/20 - 09/5/20 for approximately 6 months days. <br />I, the undersigned, certify that I am the owner of the respective property, or am qualified to <br />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 />Gl% i <br />Signature of App scant •Title <br />Y:IFORN56TEMPIATES'ENptORCHAEIRPEItMRPPPIlGT10Htla (f6g8) <br />3/9/20 <br />