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APPLICATION FOR ENCROACHMENT PERMIT <br />PLEASE PRINT: <br />Date <br />4/30/19 <br />To: San Joaquin County <br />Department of Public Works <br />Applicant <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 />plans may be <br />JOB # <br />APN <br />EXP.DATE <br />VALID <br />STREET <br />AREA <br />FORMS <br />NOTES <br />OFFICE USE ONLY <br />REF # <br />CR # <br />Ig t <br />to / al4l,7 DRIVEWAYS: <br />s4-elPonJ ,- <br />ei,49+' <br />7 <br />QUAD '15TYPE (2)• l 'I/a'toli5i r/e- c /- <br />J , Pz5 r f<fE/=1 <br />reed s" <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 permissionto excavate, construct and/or otherwise encroach on County Highway Right -of -Way on <br />the North side of W Ripon Rd approximately 450' ee mile East <br />Of 5 Mohler Rd I <br />Ripon , by performing the following work (escription of work): <br />excavate (1) 5' x 5' bellhole trench for a new Ras service <br />Work will commence on or after 6 1 19 - 11 25 19 for approximately6 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 />Signature of App scant - Title <br />YPORM9& TEMPUACSIENMOACHMBNT PEPMIT APPLICATION d (0&08) <br />4/30/19 <br />Date