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APPLICATION FOR ENCROACHMENT PERMIT <br />PLEASE PRINT: <br />Date 3/27/24 <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 />STDivPGEPermits@pge.com <br />(Email Address) <br />Sketch (Detailed plans may be submitted) <br />PM 35514244 <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 />6/1/2024 TO 12/1/2024 DRIVEWAYS: <br />Henry Rd. <br />QUAD <br />Aerial Work <br />SS/WW <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 West side of S Henry Rd approximately 0.26 Q feet/ Q mile North <br />of Dodds Rd Farmington by performing the following work (description of work): <br />Install OH fuse & new service <br />Work will commence on or after 6/1/24 <br />for approximately <br />180 <br />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 />3/27/24 <br />Signature of Applicant - Title Date <br />