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APPLICATION FOR ENCROACHMENT PERMIT <br />PLEASE PRINT: <br />Date 8/15/23 <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 />11/6/2023 TO 5/C,/?0?4 DRIVEWAYS: <br />Kasson Rd. <br />Tracv QUAD SW <br />Traffic Control Devices <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 E side of Kasson Rd approximately 2360 _ (F feet/ ©mile NW <br />of W Lorenzen Rd Manteca by performing the following work (description of work): <br />Traffic Control to replace pole in private property. <br />PM#31656138 <br />Approx. 25' from EP & 5' from ROW <br />Work will commence on or after 11/6/23 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 />Dom" / 8/15/23 <br />Signature of Applicant - Title Date <br />