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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 3517%66 <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 />9 h 2o <br />25 za 0 Cj' 20 DRIVEWAYS: <br />" <br />�oroeArar/ QUAD 15�5 <br />aPiAcEMEAYr <br />4WAf <br />�JG rl�sTl� <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 B St approximately 127' ee mile North <br />of E 6th St Stockton by,performing the following work ( escription of work): <br />pole replacement, set new pole hard west of existing pole <br />Work will commence on or after 2/25/20 - 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 Applicant -Title <br />Y;IFORMS &TEMPLATESIENCROACNMENTPERMIT APPLICATION.dw (08108) <br />1/29/20 <br />