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APPLICATION FOR ENCROACHMENT PERMIT <br />PLEASE PRINT: <br />Date 11/8/19 <br />To: San Joaquin County <br />Department of Public Works <br />PG&C PM 31464045 <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 />70&x,�.� L+ REF # <br />CR # <br />'p /zoo <br />/ Oo TO 2.6 DRIVEWAYS; <br />fisat <br />QUAD <br />ff <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 East side of West Ln approximately 346' ee mile South <br />of E Fulton St Stockton by performing the following work ( escription of work); <br />Restore t after emergency pole removal <br />Work will commence on or after 1/1/20 - 6/1/20 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:IFORMS & TEMPLATESIENCROACHMENT PERMIT APPLICATION.doc <br />11/8/19 <br />Date <br />