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APPLICATION FOR ENCROACHMENT PERMIT <br />PLEASE PRINT: <br />Date 6/17/22 <br />To: San Joaquin County <br />Department of Public Works <br />Pacific Gas & Electric - Candice Laccetti <br />(Applicant Name) <br />1524 N. Carpenter Rd <br />(Mailing Address) <br />Modesto, CA 95351 <br />(City, State, Zip Code) <br />(925) 303-9471 <br />(Area Code - Telephone Number) <br />C6L5@pge.com / STDivpgepermits@pge.com <br />(Email Address) <br />Sketch (Detailed plans may be submitted) <br />PM 35315774 <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 3/15/2023 DRIVEWAYS: <br />Lyons Rd. <br />ipon QUAD <br />Pole Installation <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 North side of Lyons Rd approximately 163 _ (F) feet/ ©mile West <br />of Austin Rd Manteca by performing the following work (description of work): <br />Traffic control to install new pole <br />Work will commence on or after 9/15/22 <br />for approximately <br />180 <br />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 />6/17/22 <br />Signature of Applicant - Title <br />Date <br />