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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 />PU(k PM 351 2646 <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'bAMx/ <br />TYPE <br />FORMS <br />NOTES <br />OFFICE USE ONLY <br />REF # <br />CR # <br />0 O llil4& DRIVEWAYS: <br />AIj4dV ,1b, <br />QUAD <br />46s�r W45) id <br />Crew to call SJ County Inspector at (�09) �JJ�®721 � to 72 hours �e�®�'� work starts. <br />When calling, crew shall request "rain clearance" for any work during winter months <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 Benson Ferry Rd approximately 163' ee mile East <br />of Thornton Rd Galt by performing the following work ( escription of work): <br />Pole and transformer replacement <br />Work will commence on or after 02/15/20 - 08/25/20 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:IFORMS &TEMPLATESIENCROACHMENTPERMIT APPLICATION.dac (08108) <br />1/29/20 <br />Date <br />