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APPLICATION FOR ENCROACHMENT PERMIT <br />PLEASE PRINT; <br />Date 11-12-2019 <br />To; San Joaquin County <br />Department of Public Works <br />PGE PM 31455193 <br />(Applicant Name) <br />3136 Boeing Way <br />(Mailing Address) <br />Stockton, CA 95206 <br />(City, State, Zip Code) <br />(209) 210-0454 <br />(Area Code - Telephone Number) <br />t8m3@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 />7601005UQ 0(0 REF # <br />j CR # <br />21112.0 <br />►21 fO 2 t 2a DRIVEWAYS: <br />�� QUAD <br />=3qL#qr6OISPL &xS <br />SRr,Gt�. pui <br />Crew to call SJ County Inspector at (209) 953-7421 4.8 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 />Pole is approximately 12 feet from edge of road. <br />The undersigned hereby applies for permission to excavate, construct and/or otherwise encroach on County Highway Right -of -Way on <br />the North Slde Of East Kettleman Lane approximately 3,825 feet/mlle East <br />of North Locust Tree Rd by performing the following work (description of work): <br />Replace insulators. <br />Work will commence on or after tz-�z-zo�9 <br />for approximately? <br />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 />T W Mal� <br />Signature of Applicant -Title <br />Y:IFORMS & TEMPLATESIENCROACNMENi PERMIT APPLICATION.doc (08I08) <br />11-12-2019 <br />Date <br />