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APPLICATION FOR ENCROACHMENT PERMIT <br />PLEASE PRINT: <br />Date <br />To: <br />San Joaquin County <br />Department of Public Works <br />PG&E PM 35046971 <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 />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 andlor otherwise encroach on County Highway Right -of -Way on <br />the West side of Manthey Rd & W Hospital Rd approximately ee mile <br />of French Camp by performing the following work ( escription of work): <br />PG&E to bore 1175' of 4" Plastic main 2' into the road, and trench 20' of 4" Plastic Service <br />Work will commence on or after <br />0 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 6 TEMPLATESIENCROACNMENT PERMIT APPLICATION.dx (08106) <br />2/7/20 <br />Date <br />OFFICE USE ONLY <br />JOB # <br />it;wtra -Q <br />REF # <br />APN <br />CR # <br />EXP,DATE <br />/ <br />010 <br />VALID <br />�° y' d6 <br />TO a 9 1 DRIVEWAYS: <br />STREET <br />AREA <br />oxftwrsy <br />5Tac/cjvnl <br />9D , <br />QUAD e <br />TYPE <br />FORMS <br />NOTES <br />'amu, NoLL4; <br />95,l�,/1✓ 4 <br />Bo,6S� �r� , <br />Tc.s �.d/ <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 andlor otherwise encroach on County Highway Right -of -Way on <br />the West side of Manthey Rd & W Hospital Rd approximately ee mile <br />of French Camp by performing the following work ( escription of work): <br />PG&E to bore 1175' of 4" Plastic main 2' into the road, and trench 20' of 4" Plastic Service <br />Work will commence on or after <br />0 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 6 TEMPLATESIENCROACNMENT PERMIT APPLICATION.dx (08106) <br />2/7/20 <br />Date <br />