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APPLICATION FOR ENCROACHMENT PERMIT <br />PLEASE PRINT: <br />Date <br />10/16/19 <br />To: San Joaquin County <br />Department of Public Works <br />PG(XE PM 35105994 <br />(Applicant Name) <br />1524 N CarpenterRd <br />(Mailing Address) <br />Modesto, CA 95351 <br />(City, State, Zip Code) <br />209-857-0181 <br />(Area Code -Telephone Number) <br />WAT8@PGE.COM <br />(Email Address) <br />Sketch (Detailed plans may be submitted) <br />JOB # <br />APN <br />EXP, DATE <br />VALID <br />STREET <br />AREA <br />TYPE <br />FORMS <br />NOTES <br />OFFICE USE ONLY <br />f. �} REF # <br />CR # <br />S 1 7a <br />I1 2a DRIVEWAYS; <br />G1QME1 LtA ST. <br />j@570c;kwt% QUAD ES <br />!E:& , t?OLC (1M PA VeM&&*4 l <br />*,pq4u1, <br />C� �' •� <br />Crew to call SJ County Inspector at (209) 953-7421 48 to 72 hours before work starts. <br />When calling, crew shall request "rain clearance" for any work during winter months <br />November through March <br />The undersigned hereby applies for permission to excavate, construct and/or otherwise encroach on County Highway Right -of -Way on <br />the South side of Carmellia St approximately 420' ee mile West <br />of Walker Ln Stockton., by performing the following work ( escription of work); <br />4x4 bellhole to cut off gas service at main <br />Work will commence on or after 11/20/19 - 05/1/20 for approximately 6 months 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 <br />Y:IFCRMS L TEMPLATESIENCRCACHMENT PERMIT APPLICATION.doc (00108) <br />10/16/19 <br />Date <br />