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PLEASE PRINT: <br />APPLICATION FOR ENCROACHMENT PERMIT <br />Date 12/20/22 <br />To: San Joaquin County <br />Department of Public Works <br />PG&E <br />(Applicant Name) <br />4055 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 <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 />1/8/2023 TO 4/15/2023 DRIVEWAYS: <br />Scotts Ave. <br />Stockton QUAD WS <br />Pole Replacement ' <br />SS/VWN <br />Special Conditions <br />****POLE <br />NOT TO BE SET ANY CLOSER TO THE EDGE OF <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 S side of W Scotts Ave approximately 105' ee mile E <br />Of W Modesto Ave , Stockton , by performing the following work (description of work): <br />4' from EP & 18' from Centerline <br />PM#31501017 <br />Work will commence on or after 1/8/23 for approximately days. <br />1, 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 />Da,61� F Ozl Permit Facilitator 12/20/22 <br />Signature of App cant -Title Date <br />YVCRItShcE1PlAlESfIICRO,lCHI%R P WF AW16.<rZZ' 1 <br />