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PLEASE PRINT: <br />Date 09/21/21 <br />PM 35227903 <br />APPLICATION FOR ENCROACHMENT PERMIT <br />To: San Joaquin County <br />Department of Public Works <br />PGE <br />(Applicant Name) <br />560 West 15th Street <br />(Mailing Address) <br />Merced, CA 95340 <br />(City, State, Zip Code) <br />209.355.5087 <br />(Area Code - Telephone Number) <br />CYSO@pge.com <br />(Email Address) <br />may <br />Off -ramp 269 Acampo Rd <br />JOB # <br />APN <br />EXP.DATE <br />VALID <br />STREET <br />AREA <br />TYPE <br />FORMS <br />NOTES <br />OFFICE USE ONLY <br />730052 REF # <br />CR # <br />TO DRIVEWAYS: <br />Hwy 99 Frontage Rd. <br />Acampo QUAD NE <br />Traffic COntrol Devices <br />SSANVV <br />Special Conditions <br />The undersigned hereby applies for permission to excavate, construct and/or otherwise encroach on County Highway Right -of -Way on <br />the side of approximately feet/mile <br />of , by performing the following work (description of work): <br />traffic Control Only. <br />Work will commence on or after 01/31/2022 for approximately 02/05/2022 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 />V]FORMS&TENPIATEIENCROACHMEN T PERMIT APPLICATION dov(W&OP <br />09/21/2021 <br />Date <br />