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APPLICATION FOR ENCROACHMENT PERMIT <br />PLEASE PRINT: <br />Date 2/7/20 <br />To: San Joaquin County <br />Department of Public Works <br />PG&E PM 44113636 <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 <br />7�o�5-oa•� <br />8 iS Zo <br />? ZS` Zo TO <br />`,002LOA1, 4n/ <br />QUAD <br />.�iL <br />ONLY <br />REF # <br />CR # <br />1� Zo DRIVEWAYS: <br />it�6 <br />vis ti <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 and/or otherwise encroach on County Highway Right -of -Way on <br />the North side of E I<ettleman Ln approximately 240' ee mile West <br />of Alpine Rd Lodi by performing the following work ( escription of work): <br />Broken clapper on existing pole, all overhead work <br />Work will commence on or after 2/25/20 - 08/5/20 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 Applicant -Title <br />Y:IFORMS $ TEMPLATESIENCROACHMENT PERMIT APPLICATION.doc (08108) <br />2/7/20 <br />Date <br />