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APPLICATION FOR ENCROACHMENT PERMIT <br />PLEASE PRINT: <br />Date 1/7/22 <br />To: San Joaquin County <br />Department of Public Works <br />PG&E PM 35306627 <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 />730052 REF # <br />CR # <br />1/25/2022 TO 8/1/2022 DRIVEWAYS: <br />Welty Rd. <br />Vernalis QUAD SW <br />Pole Replacement <br />SSMNy <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 Welty Rd approximately 46' ee)Mile North <br />of Hwy 33 Vernalis by performing the following work (description of work): <br />Pole replacement. set in same hole <br />Work will commence on or after 1/25/22 - 07/28/22 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 />1) , 14y4Aai2e <br />Signature of App scant - Title <br />V]FORN6&TENPIATEIENCROACHMEN T PERMIT APPLICATION dov(W&OP <br />1/7/22 <br />Date <br />