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APPLICATION FOR ENCROACHMENT PERMIT <br />PLEASE PRINT: <br />Date <br />To: San Joaquin County <br />Department of Public Works <br />PG&E PM 35132564 <br />(Applicant Name) <br />1524 N Carpenter Rd <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 />isooaA REF # <br />CR # <br />T11 Ls <br />4 4 TO o5j20 DRIVEWAYS: <br />126E lr igo , <br />Loop QUAD M6 <br />Ott, Moc.e�TA� <br />$�vW 2tOk t Cott AG Cy <br />'' �G AL. 6UP Pn i5g& #$ <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 W SARGENT RD approximately 1 518' ee mile West <br />of Devries Rd Lodi by performing the following work ( escription of work): <br />Excavate 5' x 5' bell hole, trench for gas service. <br />Work will commence on or after 11/25/19 - 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 />1 01 <br />Signature of Ap <br />-Title <br />Y:IFORMS 8 TEMPLATESIENCROACHMENT PERMIT APPLICATION.doc (08108) <br />11/1/19 <br />Date <br />