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PM#74025580 <br />1-549 <br />PLEASE PRINT: <br />APPLICATION FOR ENCROACHMENT PERMIT <br />To: San Joaquin County <br />Department of Public Works <br />(Applicant Namej <br />4155 E Childs Ave <br />(Mailing Address) <br />Merced, CA, 95401 <br />(City, State, zip Code) <br />408-605-6657 <br />(Area an Tala hnna <br />Number) <br />DDMN@PGE.COM <br />(Email Address) <br />Sketch (Detailed plans may be submitted) <br />Crew to call SJ County Inspeetor 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 t <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 VV Ripon Rd approximately<�rcXr ee mile Warr <br />of by performing the following work ( escnpiion of work); <br />will commence on or after Late October or Early November for approximately <br />days. <br />I, the undersigned, certify that I am the owner of the respective properly, or am qualified to represent the ownerand agree to do the <br />work desc�ibetl above in accordance with the rules and regulations of San Joaquin Courity and subject io inspection and approval. <br />�G:vrc�i ��x, <br />Permit Facilitator <br />10-8-19 <br />Signature of App cant • Tltle <br />vAFoQUu thuMtFs FJ;atoAcrnaR Mawr Arpuuma1 ax p:, Hca) <br />Date <br />OFFICE USE ONLY <br />JOB # <br />%3REF # <br />APN <br />CR # <br />EXP. DATE <br />!� 5 19 <br />VALID <br />ithS 9 To !L Ir ) rf DRIVEWAYS. <br />STREET <br />&jvj. Z1104I) a i <br />AREA <br />TYPE <br />« QUAD d(z ` <br />ire I ( Ra" TCP <br />FORMS <br />%Ajw, 2-i9 <br />NOTES <br />Alt <br />o r w'.44 'kv% ke- %Av%4 rt <br />- 40 04 <br />t5 i� <br />I{ t 01�i v <br />T <br />Crew to call SJ County Inspeetor 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 t <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 VV Ripon Rd approximately<�rcXr ee mile Warr <br />of by performing the following work ( escnpiion of work); <br />will commence on or after Late October or Early November for approximately <br />days. <br />I, the undersigned, certify that I am the owner of the respective properly, or am qualified to represent the ownerand agree to do the <br />work desc�ibetl above in accordance with the rules and regulations of San Joaquin Courity and subject io inspection and approval. <br />�G:vrc�i ��x, <br />Permit Facilitator <br />10-8-19 <br />Signature of App cant • Tltle <br />vAFoQUu thuMtFs FJ;atoAcrnaR Mawr Arpuuma1 ax p:, Hca) <br />Date <br />