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APPLICATION FOR ENCROACHMENT PERMIT <br />PLEASE PRINT: <br />Date 8/15/22 <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 35325293 <br />JOB # <br />APN <br />EXP. DATE <br />VALI D <br />STREET <br />AREA <br />TYPE <br />FORMS <br />NOTES <br />OFFICE USE ONLY <br />730052 REF # <br />CR # <br />9/5/2022 TO 3/1/2023 DRIVEWAYS: <br />Sargent Rd. <br />Lodi QUAD NW <br />Pole Replacement & Aerial Work <br />SS/WW <br />Conditions <br />_Special <br />The undersigned hereby applies for permission to excavate, construct and/or otherwise encroach on County highway right-of-way on <br />the Both side of Sargent Rd. approximately 0.28 0 feet/ Q mile East <br />of Moore Rd Lodi , by performing the following work (description of work): <br />Traffic control to replace pole (in same location) and OH facilities <br />Work will commence on or after 9/5/22 <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 />8/15/22 <br />Signature of Applicant - Title <br />Date <br />