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APPLICATION FOR ENCROACHMENT PERMIT <br />PLEASE PRINT: <br />Date 2/25/20 <br />To: San Joaquin County <br />Department of Public Works <br />PG&E PM 31248666 <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.CCM <br />(Email Address) <br />Sketch (Detailed plans may be submitted) <br />OFFICE USE ONLY <br />JOB # 4 REF # <br />APN CR # <br />EXP. DATE W ( I ?-u <br />VALID 3 it zo TO DRIVEWAYS: <br />STREET TP_ALH F�VD. <br />AREA QUAD SW <br />TYPE 4Z)- f 61.6 12H.PLAcASMC&OT 4 <br />FORMS Sc�lww <br />NOTES it SpdU,gG A)DlvY! ass a <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 East/West side of S Tracy Blvd approximately 1.19 ee mile South <br />of HWY 4 Stockton by performing the following work ( escription of work): <br />Replace 2 poles and overhead service <br />Work will commence on or after 3/25120 - 09/25/20 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 <br />nt -Title <br />Y:IFORMS & TEMPLATESIENCROACRMENT PERMIT APPLICATION.dw (08108) <br />2/25/20 <br />Date <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 East/West side of S Tracy Blvd approximately 1.19 ee mile South <br />of HWY 4 Stockton by performing the following work ( escription of work): <br />Replace 2 poles and overhead service <br />Work will commence on or after 3/25120 - 09/25/20 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 <br />nt -Title <br />Y:IFORMS & TEMPLATESIENCROACRMENT PERMIT APPLICATION.dw (08108) <br />2/25/20 <br />Date <br />