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APPLICATION FOR ENCROACHMENT F'1111=4311011 I <br />PLEASE PRINT: <br />To: <br />San Joaquin County <br />Department of Public Works <br />PG&E PM 31423602 <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 />OFFICE USE ONLY <br />17A Qo O�•� REF # <br />CR # <br />711r 10 <br />ZS TO DRIVEWAYS: <br />mtip pe. <br />y7te k7o ,/ QUAD :5W <br />Aog, AG Gt/a¢K <br />�' �SiAG Ce�tl�lTiLlrICS " <br />Crew to call SJ County Inspector at (209) 953-7421 48 to �2 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 S Inland Dr approximately 2,990 ee mile South <br />of W Kingston School Rd Stockton , by performing the following work ( ascription of work): <br />ace overhead cross arm on existing sole. All overhe <br />Work will commence on or after 1/25/20 - 07/5/20 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 <br />cant -Title <br />Y:IFORMS & TEMPLATESIENCROACNMENT PERMIT APPLICATICN.dac <br />1/13/20 <br />Date <br />