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APPLICATION FOR ENCROACHMENT PERMIT <br />PLEASE PRINT: <br />Date 6/20/23 <br />To: San Joaquin County <br />Department of Public Works <br />Pacific Gas & Electric <br />(Applicant Name) <br />4155 E Childs Ave <br />(Mailing Address) <br />Merced, CA, 95340 <br />(City, State, Zip Code) <br />(408) 605-6657 <br />(Area Code - Telephone Number) <br />DDHN@PGE.COM <br />(Email Address) <br />Sketch (Detailed plans may be submitted) <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 />7/17/2023 TO 12/17/2023 DRIVEWAYS: <br />Peltier Rd. <br />Acampo QUAD NE <br />Aerial Work <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 N side of E Peltier Rd approximately 100 _ Q feet/ Q mile E <br />of N Kennefick Rd Youngstown by performing the following work (description of work): <br />Repair/Replace overhead facilities, no excavation <br />PM#45582554 <br />8' to EP, 22' Centerline & 16' to ROW <br />Work will commence on or after 7/17/23 for approximately 1 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 />Daw'd 6/20/23 <br />Signature of Applicant - Title Date <br />