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APPLICATION FOR ENCROACHMENT PERMIT <br />PLEASE PRINT: <br />Date 8/12/23 <br />To: San Joaquin County <br />Department of Public Works <br />Candice Laccetti-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 />STDivPGEPennits@pge com <br />(Email Address) <br />Sketch (Detailed plans may be submitted) <br />PM 35422110 <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 />TO DRIVEWAYS: <br />mmTm <br />ivianteca QUAD <br />Pole Replacement <br />SSNVVV <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 _ wen — side of — — Tinn_RRd _ _ _ _approximately_ 0 1 — ®feet/ Qmile_ s"th <br />of E Wood`" Ave Manna by performing the following work (description of work): <br />Traffic control to replace pole & install OH service <br />Work will commence on or after_ — — — 10/25/23 _ _ _ for approximately 180 _days. <br />I, the undersigned, certitythat I am the owner of the respective property, oram qualified to representthe 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 />8/1223 <br />Signature of Applicant - Title <br />Date <br />