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APPLICATION FOR ENCROACHMENT PERMIT <br />PLEASE PRINT: <br />Date 1/16/20 <br />To: San Joaquin County <br />Department of Public Works <br />PUot PM 43480179 <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 />VVAT8C@PGE.00M <br />(Email Address) <br />Sketch (Detailed plans may be submitted) <br />JOB # <br />APIN <br />EXP. DATE <br />VALID <br />STREET <br />AREA <br />TYPE <br />FORMS <br />NOTES <br />OFFICE USE ONLY <br />73oosol - REF # <br />CR # <br />0 k Zo <br />a 1xil TO e $ Lzo DRIVEWAYS: <br />aTH Sr. <br />Csrz$CVTbn! QUAD 56 <br />Aclsn.sT Fx+sf,U� ALA <br />VAIK <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 North side of E 9th St approximately 318' ee mile East <br />of Bieghle St Stockton by performing the following work ( escription of work): <br />re -align leaning pole <br />Work will commence on or after 2/25/19 - 08/15/20 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 Applicant -Title <br />Y:IFDRMS G TEMPLATESIENCRDACHMENT PERMIT APPLICATIDN.doc (OBIOA) <br />1/16/20 <br />Date <br />