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APPLICATION FOR ENCROACHMENT PERMIT <br />PLEASE PRINT: <br />Date 1022 <br />To: San Joaquin County <br />Department of Public Works <br />Pacific Gas & Electric <br />Name) <br />4155 E Childs Ave <br />(Mailing Address) <br />Merced, CA 95340 <br />(City, State, Zip Code) <br />(408) 6056657 <br />(Area Code - Telephone Number) <br />DDHN@PGE.OGM <br />(Email Address) <br />Sketch (Detailed plans may be submitted) <br />JOB # <br />APN <br />EXP.DATE <br />VALID <br />STREET <br />AREA <br />TYPEoP-Pi—c–ement <br />FORMS <br />NOTES <br />OFFICE USE ONLY <br />730052 REF # <br />CR # <br />10/23/2023 TO DRIVEWAYS: <br />'rP�Of <br />Manteca QUAD <br />SSMNV <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 N— _side of — — _Airport Rd _ _ _ _approximately – _i— _Tfeet/Qmile– E— <br />of Derham FevvRd mdnRca by performing the following work (description of work): <br />Replace Pole <br />PMR31655285 <br />8'EP&10'POW <br />Work will commence on or after_ — — — 10/23/23 _ _ _ _ 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 />T%2w Z111i13it <br />Signature of Applicant - Title <br />10223 <br />Date <br />