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APPLICATION FOR ENCROACHMENT PERMIT <br />PLEASE PRINT: <br />Date 2/1523 <br />To: San Joaquin County <br />Department of Public Works <br />Pacific Gas & Electric- Candice Laccetri <br />(Applicant Name) <br />1524 N. Carpenter Rd <br />(Mailing Address) <br />Modesto, CA 95351 <br />(City, State, Zip Code) <br />(925) 303 9411 <br />(Area Code - Telephone Number) <br />C0L5@pge com / STOivpgepennits@pge corn <br />(Email Address) <br />Sketch (Detailed plans may be submitted) <br />PM 35391232 <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 />a112023 TO 101112023 DRIVEWAYS: <br />undenvood Rd. <br />Acarl QUAD NE <br />Pole Replacement&Aerial Work <br />ssMW <br />Special Conditlons <br />The undersigned hereby applies for permission to excavate, construct and/or otherwise encroach on County highway right-of-way on <br />the _ Ivorcn _ side of — — eundemood Rd approximately_ oia— ®feet/ Qmile_ east <br />of eruella Rd Aeampo by performing the following work (description of work): <br />Traffic control to replace ole and OH facilities/service. <br />Work will commence on or after_ — — — 4n/23— — — _ for approximately_ — 1e0_ _days. <br />I, the undersigned, certitythat I am the owner of the respective property, oram qualified to representthe 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 />2/1523 <br />Signature of Applicant - Title <br />Date <br />