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APPLICATION FOR ENCROACHMENT PERMIT <br />PLEASE PRINT: <br />Date 12/13/19 <br />To: San Joaquin County <br />Department of Public Works <br />PG&E PM 35134954 <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 />VVAT8@PGE.00M <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 />1;�OU L4 REF # <br />CR # <br />ell A to <br />/ y�%0 �3 120 DRIVEWAYS: <br />y L, a <br />`tel QUAD <br />L .G <br />S �qG G'ru3a7'n D!-�5 <br />Crew to call SJ County Inspector at (�09) 953-741 4� to �� hours before work starts. <br />When calling, crew shall request "rain clearance" for any work during winter months <br />November <br />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 Harney Ln approximately 96ee mile West <br />of 99 Frontage Rd Lodi by performing the following work ( Description of work): <br />lace recloser on existing pole. *All overhead work <br />Work will commence on or after 01/25/20 - 07/25/20 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 <br />cant -Title <br />Y:IFORMS 8 TEMPLATESIENCROACHMENT PERMIT APPLICATIOtJ.dac <br />12/13/19 <br />Date <br />