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APPLICATION FOR ENCROACHMENT PERMIT <br />PLEASE PRINT: <br />Date �-- z Z� <br />To: San Joaquin County <br />Department of Public Works <br />PGE <br />(Applicant Name) <br />3136 Boeing Way <br />(Mailing Address) <br />Stockton Ca, 95206 <br />(City, State, Zip Code) <br />(408)316-1767 <br />(Area Code - Telephone Number) <br />STDivPGEPerrnits@pge.com - <br />(Email Address) <br />plans may be submitted) <br />- 1?L <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 />-15(202 10 211519094 DRIVEWAYS: <br />-61'6 Rd <br />I1FaFizin QUAD NI F <br />Aerial Wnrk <br />ss <br />ell <br />Cyt <br />The undersigned hereby applies for p emission to excavate, construct and/or otherwise encroach on County highway right-of-way on <br />the side of /U 122 approximately d// ®feeUQmile U <br />of o%w 7r, S ck 1=^ by performing the following work (description of work): <br />a VG s,r - . � <br />Work will commence on or after -17- 7,-7 for approximately leo 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 des imLregulations of San Joaquin County and subject to inspection and approval. <br />Si n Applicant - Title Date <br />