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APPLICATION FOR ENCROACHMENT PERMIT <br />PLEASE PRINT: <br />Date 1/3/20 <br />To: San Joaquin County <br />Department of Public Works <br />PG&E PM 35142002 <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 <br />JOB # <br />APN <br />EXP. DATE <br />VALID <br />STREET <br />OFFICE USE ONLY <br />%✓1ew7_4 REF # <br />CR # <br />g i2, <br />l g 2 0$Eta DRIVEWAYS: <br />df r2ED66 Q. <br />AREA <br />TYPE <br />FORMS <br />NOTES <br />QUAD 5 A/ <br />/L NolA. -rm*" 6p, Orr 5tt31Jt,P4& <br />Ss *Ad, 2. z9 <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 Stoneridge Dr approximately 1,120' ee mile South <br />Of Grant Line Rd Tracy , by performing the following work (description of work): <br />excavate (1) 4' x 4' bell hole; trench for new gas service <br />Work will commence on or after 1/25/20 - 07/25/20 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 />(,t) 1/3/20 <br />Signature of App scant • Title Date <br />Y:NOUS& iENPIAIESEHMWHN PENH PP MTIOMd M) <br />