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APPLICATION FOR ENCROACHMENT PERMIT <br />PLEASE PRINT: <br />Date 10/2/23 <br />To: San Joaquin County <br />Department of Public Works <br />Candice Laccetti - PG&E <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 />STDivPGEPermits@pge.com <br />(Email Address) <br />Sketch (Detailed plans may be submitted) <br />IWLTA 993M,IR1'Ici11.1 <br />JOB # <br />APN <br />EXP. DATE <br />VALID <br />STREEToc��f- <br />AREA <br />TYPE <br />FORMS <br />NOTES <br />OFFICE USE ONLY <br />730052 REF # <br />CR # <br />121112u23 TO 61'DRIVEWAYS: <br />Lockeford QUAD NE <br />le -ins <br />SS/WW, R-29, Trench Cut Policy <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 Both side of Locke Rd approximately 3319 _ (F) feet/ ©mile West <br />of Hwy 12/88 Lockeford by performing the following work (description of work): <br />Excavate 5x5 bell hole then trench to relocate gas service. Restoration to follow. <br />Work will commence on or after 12/1/23 <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 />10/2/23 <br />Signature of Applicant - Title <br />Date <br />