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APPLICATION FOR ENCROACHMENT PERMIT <br />PLEASE PRINT; <br />Date 11/1/19 <br />To: San Joaquin County <br />Department of Public Works <br />PG&E PM 35132375 <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 />OFFICE USE ONLY <br />JOB # 1;00: 01-1% REF # <br />APN CR # <br />EXP. DATE $ 2a <br />e� <br />VALID 2q TO i zo DRIVEWAYS: <br />STREET m6lsa0 API <br />AREA Am fb QUAD jVW <br />TYPE ��M� TR -Et StIouL06Q <br />FORMS %4dkv, .k 24 <br />NOTESPsGALCa�s•�rnbl�S'' <br />� ✓E <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 North side of E Emerson Rd approximately 1,121 ee mile West <br />of 99 Frontage Rd Acampo by performing the following work ( escription of work): <br />Excavate (1) 5' x 5' bell hole, cut off existing gas service, trench for new gas service <br />Work will commence on or after 11/29/19- 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 />I IN <br />Signature of Applicant -Title <br />Y:IPORMS & TEMPLATESIENCROACHMENi PERMIT APPLICATION.doc (08108) <br />11/1/19 <br />Date <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 North side of E Emerson Rd approximately 1,121 ee mile West <br />of 99 Frontage Rd Acampo by performing the following work ( escription of work): <br />Excavate (1) 5' x 5' bell hole, cut off existing gas service, trench for new gas service <br />Work will commence on or after 11/29/19- 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 />I IN <br />Signature of Applicant -Title <br />Y:IPORMS & TEMPLATESIENCROACHMENi PERMIT APPLICATION.doc (08108) <br />11/1/19 <br />Date <br />