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:9$1,10 0 U 14 14 <br />APPLICATION FUR ENCROACHMENT PERMIT <br />PLEASE PRINT: <br />10_ 8• I g <br />Date <br />To; San Joaquin County <br />Department of Public Works <br />PG&E <br />(Applicant Narne) <br />4155 E Childs Ave <br />(Mailing Address) <br />Merced, CA, 95401 <br />(City, State, zip Code) <br />408-605-6657 <br />Area Code •Telephone Number) <br />DDHN@PGE.COM <br />(Email Address) <br />Sketch (Qetailed plans may be submitted) <br />Jos # <br />APN <br />EXP, DATE <br />VALID <br />STREET <br />AREA <br />TYPEpES <br />FORMS <br />NOTESi5A6evX+L <br />OFFICE USE ONLY <br />73006 KA REF <br />CR # <br />1 10 <br />r y<t 4 TO I o DRIVEWAYS. <br />404 •ori, 4JOW A* <br />Lon Q AD t/ ' <br />i <br />5s�wr�J <br />6AWJT)DOS " <br />depth &general <br />condition of pipeline. Identify if pipeline is <br />damaged. Drill 1/2" hole to <br />allow connection <br />to soils, <br />spacing <br />determined <br />by depth <br />of pipe "Fast process, 1 hole/minute. hole is filled <br />with backer rod & 3M loop <br />detector sealant <br />5000. <br />Crew to call SJ County Inspecto►• 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 io excavate, construct andlor otherwise encroach on County Highway Right -of -Way on <br />the Noun side of W Harney Ln approximately ee mile <br />of by performing the following work ( escription of work); <br />(Cathodic Protection Close Interval Survey) <br />Assess <br />the location, <br />depth &general <br />condition of pipeline. Identify if pipeline is <br />damaged. Drill 1/2" hole to <br />allow connection <br />to soils, <br />spacing <br />determined <br />by depth <br />of pipe "Fast process, 1 hole/minute. hole is filled <br />with backer rod & 3M loop <br />detector sealant <br />5000. <br />Work will commence on or after 1 r -? P ° 9 'for approximately 1-z 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 />/0 <br />Dace Permit Facilitator <br />Date <br />Signature of App rcant - Title <br />Y.iFOR4li i TE4'r'IATES'EI;CROn4Nt5`R PfkWT ES?LJCATIO!1 d:c Q:uGi) <br />