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APPLICATION FOR ENCROACHMENT PERMIT <br />PLEASE PRINT: <br />Date 11/2/2023 <br />To: San Joaquin County <br />Department of Public Works <br />Pacific Gas and Electric - PM 45903994 <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 />JOB # <br />APSE] <br />EXP.DATE <br />VALID <br />STREETou—C <br />AREA <br />TYPE <br />FORMS <br />NOTES <br />OFFICE USE ONLY <br />730052 REF # <br />CR # <br />TO DRIVEWAYS: <br />ntry CTul) Blvd <br />Stockton QUAD CC <br />Traffic Control Devices <br />SS/WW <br />Special Conditions <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 SOUTH side of Country Club Blvd approximately 660 ee mile EAST <br />of Virginia Ln , Stockton by performing the following work (description of work): <br />Traffic control only for gas leak repair in City of Stockton ROW. <br />Pre/Post construction CCTV inspections may take place. <br />Work will commence on or after 11/6/2023 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 />(�e� 2 � <br />Siga I if Applicant - Title <br />V:\FORMS &TEMPLATE SSE NCR OACHMENT PERMIT APPLICATION. doc (08M) <br />11/2/2023 <br />Date <br />