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APPLICATION FOR ENCROACHMENT PERMIT <br />PLEASE PRINT: <br />Date 9/11/2020 <br />To: San Joaquin County <br />Department of Public Works <br />Pacfic Gas & Electric (PM 351 <br />(Applicant Name) <br />4155 E. Childs Ave. <br />(Mailing Address) <br />95341 <br />(City, State, Zip Code) <br />(209) 289-3276 <br />(Area Code - Telephone Number) <br />Ilrg@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 />730052-6 REF # <br />CR # <br />11/3/2020 TO 4/1/2021 DRIVEWAYS: <br />Orange Ave. <br />Escalon QUAD <br />Bell Hole, Trench <br />SSANW, R-29, Trench Cut Policy <br />Special Conditions <br />See Attached <br />The undersigned hereby applies for permission to excavate, construct and/or otherwise encroach on County Highway Right -of -Way on <br />the South side of orange Ave approximately 1,693 feet/mile East <br />of Santa Fe Rd , by performing the following work (description of work): <br />PG&E to diq 5x5 bell -hole and trench to replace qas service <br />Work will commence on or after 11/3/2020 for approximately 90 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 />Z_i-�A�,-Permit Facilitator <br />Signature of Applicant - Title <br />V]FORMS&TENPIATEIENCROACHMEN T PERMIT APPLICATION dov(W&OP <br />9/11/2020 <br />Date <br />