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APPLICATION FOR ENCROACHMENT PERMIT <br />PLEASE PRINT: <br />Date 10/16/2020 <br />To: San Joaquin County <br />Department of Public Works <br />PG&E - PM 44312316 <br />(Applicant Name) <br />6121 Bollinger Canyon Rd <br />(Mailing Address) <br />San Ramon, Ca, 94583 <br />(City, State, Zip Code) <br />925-701-1564 <br />(Area Code - Telephone Number) <br />glenten.gj@gmail.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 />730052-10 REF # <br />CR # <br />12/1/2020 <br />10/19/2020 TO 12/1/2020 DRIVEWAYS: <br />Cotton St. <br />Lockeford QUAD NE <br />Trench <br />SSMNV, R-29, Trench Cut 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 West side of Cotton St approximately 40ft feet/mile south <br />of Main St (Hwy as) Lockeford , by performing the following work (description of work): <br />PG&E to Derform Pavina/Restoral work due to leak repairs. Please see attachments. <br />Work will commence on or after or upon approval for approximately 1 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&TENPIATEIENCROACHMEN T PERMIT APPLICATION dov(W&OP <br />Date <br />10/16/2020 <br />