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APPLICATION FOR ENCROACHMENT PERMIT <br />PLEASE PRINT: <br />Date OFFICE USE ONLY <br />To:San Joaquin County JOB #REF # <br />Department of Public Works APN CR # <br />EXP. DATE <br />VALID TO <br />DRIVEWAYS: <br />(Applicant Name)STREET * <br />AREA QUAD <br />* <br />TYPE * <br />(Mailing Address)FORMS <br />NOTES <br />(City, State, Zip Code) <br />(Area Code -Telephone Number) <br />(Email Address) <br />The undersigned hereby applies for permission to excavate, construct and/or otherwise encroach on County Highway Right-of-Way on <br />the ______________ side of ___________________________________ approximately ___________________ feet/mile _________ <br />of _______________________________________, ____________________, by performing the following work (description of work): <br />Work will commence on or after _____________________________________ for approximately ________________________ 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 />Signature of Applicant -Title Date <br />Y:\FORMS & TEMPLATES\ENCROACHMENT PERMIT APPLICATION.doc (08/08) <br />Sketch (Detailed plans may be submitted) <br />3136 Boeing Way <br />Stockton, CA 95204 <br />209-857-0181 <br />WAT8@PGE.COM <br />PM 35538792 <br />4/5/24 <br />4/5/24 <br />6 ________________________ days.________________________ days.months________________________ days.________________________ days.4/20/24 4/20/24 4/20/24 4/20/24 - 11/20/2411/20/24 <br />C-O the ______________ side of ___________________________________ approximately ___________________ feet/mile _________the ______________ side of ___________________________________ approximately ___________________ feet/mile _________Robindale the ______________ side of ___________________________________ approximately ___________________ feet/mile _________the ______________ side of ___________________________________ approximately ___________________ feet/mile _________Ave the ______________ side of ___________________________________ approximately ___________________ feet/mile _________the ______________ side of ___________________________________ approximately ___________________ feet/mile _________& the ______________ side of ___________________________________ approximately ___________________ feet/mile _________the ______________ side of ___________________________________ approximately ___________________ feet/mile _________Belvedere the ______________ side of ___________________________________ approximately ___________________ feet/mile _________the ______________ side of ___________________________________ approximately ___________________ feet/mile _________Avethe ______________ side of ___________________________________ approximately ___________________ feet/mile _________the ______________ side of ___________________________________ approximately ___________________ feet/mile _________ <br />Stockton, ____________________, , ____________________, <br />maintenance work on existing existing pole. pole. NO GROUND DISTURBANCE WILL TAKE PLACE