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APPLICATION FOR ENCROACHMENT PERMIT <br />PLEASE PRINT: <br />Date 12/6/2022 <br />To: San Joaquin County <br />Department of Public Works <br />Pacific Gas and Electric - PM 45460356 <br />3136 Boeing Way <br />Stockton, CA 95206 <br />(City, State, Zip Code) <br />(209) 470-2300 <br />(Area Code - Telephone Number) <br />STDivPGEpermits@pge.com <br />(Email Address) <br />Sketch (Detailed plans may be submitted) <br />OFFICE USE ONLY <br />JOB # REF # <br />APN CR # <br />EXP.DATE <br />VALID TO DRIVEWAYS: <br />STREET <br />AREA QUAD <br />TYPE <br />FORMS <br />NOTES <br />Crew to call SJ County Inspector at (209) 953-7421 48 to 72 hours before work starts. <br />When calling, crew shall request "rain clearance" for any work during winter months <br />November through March <br />The undersigned hereby applies for permission to excavate, construct and/or otherwise encroach on County Highway Right -of -Way on <br />the WEST side of Snyder Ln approximately 3653 ee mile SOUTH <br />of Waterloo Rd Stockton by performing the following work (description of work): <br />PG&E to excavate 4' x 4' bellhole to repair gas leak. Restoration to follow. <br />Pre/Post construction CCN inspections may take place. <br />Work will commence on or after 12/12/2022 for approximately 180 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 />Siy ure if Appl cant - Title <br />V]FORN6&TENPIATEIENCROACHMEN T PERMIT APPLICATION dov(W&OP <br />12/6/2022 <br />Date <br />