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APPLICATION FOR ENCROACHMENT PERMIT <br />PLEASE PRINT: <br />Date 2023 <br />To: San Joaquin County <br />Department of Public Works <br />Pacific Gas & Electric- Candice Lacceth <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 />C6L5@pgecom / STDivpgepeunits@pge corn <br />(Email Address) <br />Sketch (Detailed plans may be submitted) <br />PM 35421913 <br />JOB # <br />APN <br />EXP.DATE <br />VALID <br />STREETw�Fr­ontag—effcT <br />AREA <br />TYPE <br />FORMS <br />NOTES <br />OFFICE USE ONLY <br />730052 REF # <br />CR # <br />31612023TO 9/15/2023 DRIVEWAYS: <br />Manteca QUAD BE <br />Bell Hole, Trench <br />SS/WW, R-29 <br />Special Conditions <br />The undersigned hereby applies for permission to excavate, construct and/or otherwise encroach on County highway right-of-way on <br />the–_ — — side of — _ HM 99 Frontage Rd_ _ _ approximately– ss0o — Qfeet/ Qmile– "_ <br />of Northland Rd Mantecaby performing the following work (description of work): <br />Excavate 5x5 bell hole to cut off gas service then trench 2in ROW to install new service. <br />Work will commence on or after_ — — — s/erez _ _ _ _ for approximately_ — 1e0_ _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 />26/23 <br />Signature of Applicant - Title <br />Date <br />