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APPLICATION FOR ENCROACHMENT PERMIT <br />PLEASE PRINT: <br />Date 72723 <br />To: San Joaquin County <br />Department of Public Works <br />Candice Lacceth PG&E <br />(Applicant Name) <br />1524 N Carpenter Rd <br />(Mailing Address) <br />Modesto, CA 95351 <br />(City, State, Zip Code) <br />(925) 303 9471 <br />(Area Code - Telephone Number) <br />STDivPGEPermits@pge com <br />(Email Address) <br />Sketch (Detailed plans may be submitted) <br />PM 35458400 & PM 35429042 <br />JQg# <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 />TO <br />—e ler�d <br />Acampo QUAD NE <br />Aerial Work & Anchor ReplaceMent <br />SSMNV <br />Special Conditions <br />DRIVEWAYS: <br />The undersigned hereby applies for permission to excavate, construct and/or otherwise encroach on County highway right-of-way on <br />theSouth side EPeloerRd approximately 0.16 ®feet/ Qmile w� <br />of Iv Elliott Rd Acempo by performing the following work (description of work): <br />Traffic control to replace anchor transformer & install new OH service <br />Work will commence on or after_ — — — 9/1/23— — — _ for approximately_ — ieo---- 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 />( <br />Signature of Applicant - Title <br />72723 <br />Date <br />