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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 43474670 <br />(Applicant Name) <br />1.524 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 />OFFICE USE ONLY <br />7�?�gREF # <br />CR # <br />$ 1 20 <br />/;y $0 9 to 41 12o DRIVEWAYS: <br />At 7 91 �jlpA,7r966 Ads <br />44)Ob QUAD A/9 <br />-rg rierc Gour�oi ZL�✓10Es <br />" 15f�2re#Ac <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 andlor otherwise encroach on County Highway Right -of -Way on <br />the East side of N 99 Frontage Rd approximately 740' ee mile South <br />of Baumbach Ln Acampo by performing the following work ( escription of work): <br />Replace pothead on existing pole. No ground disturbance will take place <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 />Signature of Appiicant -Title <br />Y'.1FCRMS & TEMPLATESIENCRCACHMENT PERMIT APPLICATI ON.doc (00108) <br />1/3/20 <br />Date <br />