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APPLICATION FOR ENCROACHMENT PERMIT <br />PLEASE PRINT, <br />Date -QRW 1(� — l — Z / <br />OFFICE USE ONLY <br />To San Joaquin County <br />JOB # <br />730052 <br />REF # <br />Department of Public Works <br />APN <br />CR # — <br />EXP. DATE <br />PGE <br />VALID <br />STREET <br />11/10/2023 TO <br />Baker Rd. <br />5/10/2024 DRIVEWAYS: <br />(Applicant Name) <br />AREA <br />Linden QUAD <br />NE <br />3136 Boeing Way <br />TYPE <br />FORMS <br />Pole Replacement <br />SS/WW <br />(Mailing Address) <br />NOTES <br />Special Conditions <br />Stockton Co. 95206 <br />(City, State, Zip Code) <br />(408)316-1767 <br />(Area Code - Telephone Number) <br />STDIvPGEPennits@pge.00m <br />(Email Address) <br />(IJetalled plans may be submitted) <br />lbeKev <br />.l f <br />The undersigned hereby applies fo permission to exvats, construct and/or otherwise encroach o County highway right-of-way on <br />the s' sof IFG✓ KL approximately 'Z (,K- QQ feeVOmile� <br />of N .'T.. 1 q I n Qv by performing the following work (description of work): <br />To replace existing Pole with new pole in same location <br />Work will commence on or after — o -14 for approximately 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 Mgsandnegu bons of San Joaquin County and subject to inspection and approval. <br />w-�/-Z3 <br />Signature of nt • Title / Date <br />