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APPLICATION FOR ENCROACHMENT PERMIT <br />PLEASE PRINT: <br />Date 12/2/19 <br />To: San Joaquin County <br />Department of Public Works <br />PG&E PM 43937400 <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 />73j(usw). �Q REF # <br />CR # <br />'7 / i6 <br />! z..� TO "J / 20 DRIVEWAYS: <br />A 4>ar XW <br />V��?,, iJ QUAD A& <br />,2ouu wiaE RAPAie 4E1zHoL <br />sr/ 49 <br />Crew to call SJ County Inspector at (209) 953-7421 4� to 72 hours before work startis. <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 andlor otherwise encroach on County Highway Right -of -Way on <br />the East side of Report Ave approximately 60ee mile South <br />of Waterloo Rd Stockton by performing the following work ( escription of work): <br />Repair broken <br />ground <br />Work will commence on or after 12/29/19 - 06/25/20 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 />ON MR I 1 <br />Signature of Appiicant •Title <br />Y:IFCRMS &TEMPIATESIENCROACHNENT PERMff APPIICATICN.dcc <br />12/2/19 <br />Date <br />