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APPLICATION FOR ENCROACHMENT PERMIT <br />PLEASE PRINT: <br />Date 6/17/23 <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 />105993MINGM-1 <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 1/11/2024 DRIVEWAYS: <br />Ray Rd. <br />Ludi QUAD <br />Amial WbTk <br />SS/WW <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 East side of N Ray Rd approximately 0.05 _ © feet/ Q mile North <br />of W Turner Rd Lodi by performing the following work (description of work): <br />Traffic control to replace OH transformer and install new OH service. <br />Work will commence on or after 7/1/23 <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 />6/17/23 <br />Signature of Applicant - Title <br />Date <br />