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APPLICATION FOR ENCROACHMENT PERMIT <br />PLEASE PRINT: <br />Date 07/20/2020 <br />To: San Joaquin County <br />Department of Public Works <br />PG&E PM 5161102 <br />(Applicant Name) <br />1524 N Carpenter Rd <br />(Mailing Address) <br />Modesto, CA 95351 <br />(City, State, Zip Code) <br />(925) 303-9471 <br />(Area Code - Telephone Number) <br />C61 5 jPC;F CQM / STF)IVPC;FF)HITS jPC;F 200 <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 />730052-4 REF # <br />CR # <br />2/1/2021 <br />7/22/2020 TO 02/01/2021 DRIVEWAYS: <br />Buck Rd <br />Acampo QUAD NE <br />Trench <br />SSMM/ R -9g Trench Cat Policy <br />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 East side of Buck Rd approximately 630 j(j_e'ernile South <br />of Underwood Rd Acampo , by performing the following work (description of work): <br />Excavate to convert overhead electrical services to underground. CCTV pre/post inspection. Restoration to follow. <br />Work will commence on or after 07/20/2020 for approximately 6 months 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 />( Ia4� L_IZ� <br />Signature of Applicant - Title <br />V]FORN6&TENPIATEIENCROACHMEN T PERMIT APPLICATION dov(W&OP <br />07/20/2020 <br />Date <br />