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•,,)UCX)'I <br />APPLICATION FOR ENCROACHMENT PERMIT <br />PLEASE PRINT: <br />Date 11/26/19 <br />To: San Joaquin County <br />Department of Public Works <br />PUot PM 35104001 <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 />��D05�o7 - <br />AeAmtz <br />6k) 1poa <br />kpm <br />OFFICE USE ONLY <br />REF # <br />CR # <br />i6 ;.o <br />0 (o rs da DRIVEWAYS: <br />(Z.)�. , <br />QUAD /V6 <br />lk4ilqL 40 64TA T/tE,u <br />L GD rrD <br />When calling, crew shall request "rain clearance" for any work during winter months <br />November through Marc <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 E FRAZIER RD & N TULLY RD approximately ee mile <br />of Linden by performing the following work ( escription of work): <br />LOC 1- Install overhead Service <br />LOC 213,4,5,6 - Install new poles for overhead service <br />LOC 7 - Install new pole with riser to make overhead service to underground service <br />nt installed conduit <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 Applicant •Title <br />Y:IFORMB &TEMPLATE8IENCRCACHMEM PERMR APPLICATICN.dac <br />11/26/19 <br />Date <br />