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APPLICATION FOR ENCROACHMENT PERMIT <br />PLEASE PRINT: <br />Date 1/14/2019 <br />To: San Joaquin County <br />Department of Public Works <br />PG&E PM 31401001 <br />(Applicant Name) <br />4040 West Lane <br />(Mailing Address) <br />Stockton, CA 95204 <br />(City, State, Zip Code) <br />(209) 470 - 2300 <br />(Area Code • Telephone Number) <br />s6pz(Lbpge.com <br />(Email Address) <br />may be submitted) <br />JOB# <br />APNCR <br />EXP. DATE <br />VALID <br />STREET <br />OFFICE USE ONLY <br />J3V!a-REF# <br /># <br />/ 9 <br />2 Q 0 ) )°/ DRIVEWAYS: <br />1L <br />Coin /tP <br />AREA <br />TYPE <br />�JN J <br />68)rgi, Gt <br />QUAD <br />k d <br />A9 <br />49' ' <br />FORMS <br />NOTES <br />w <br />Cef <br />bdri3 <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 <br />on the NORTH side of Comstock Rd at Cox Rd, <br />Aerial Pole Work by performing the following work (description of work): <br />Work will commence on or after 1/20/2019 for approximately 120 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 />�a a IES <br />1/14/2019 <br />Signature of A Itcant • Title Date <br />Y:I WS B TF1dFlAMG"CHCACHMENT PEHMIT MKICATICN. w(A% <br />