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APPLICATION FOR ENCROACHMENT PERMIT <br />PLEASE PRINT: <br />Date 1/29/20 <br />To; San Joaquin County <br />Department of Public Works <br />PG&E PM 44127965 <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 />� REF # <br />CR # <br />d7? w <br />t- jrJ" TO 9 1 20 DRIVEWAYS: <br />?NZWOME 7A <br />044PAgGA r QUAD Ale <br />SCG hWA :44 16WOrd2�'j ou5 <br />ogWltl /Z 29 <br />�" �L CLK1.at5A5'' <br />Crew to call SJ County Inspector at (209) 953-7421 �•� to �� hours before work starts. <br />When calling, crew shall request "rain clearance" for any work during winter months <br />AIME <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 Shoshone Dr approximately 62ee mile East <br />of Shawnee Way Manteca by performing the following work ( escription of work): <br />Restore pavement after emergency gas leak <br />Work will commence on or after <br />20 for approximately <br />6 months <br />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 />IN <br />Signature of Applicant -Title <br />Y:IFORMS & TEMPLATESIENCRCACHMENT PERMIT APPLICATICN.doc <br />1/29/20 <br />Date <br />