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PLEASE PRINT: <br />Date 12/05/19 <br />To: San Joaquin County <br />Department of Public Works <br />PGE PM 31402723 <br />(Applicant Name) <br />3136 Boeing Way <br />(Mailing Address) <br />Stockton. CA 95206 <br />APPLICATION FOR ENCROACHMENT PERMIT <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 />013# <br />APN <br />EXP. DATE <br />VALID <br />STREET <br />AREA <br />TYPE <br />FORMS <br />NOTES <br />OFFICE USE ONLY <br />rj?.(a REF # <br />CR # <br />47,140 �� <br />j/a �jp / tog TO Q z. DRIVEWAYS: <br />G,¢,g&yr ZiAzE RD, <br />�7'jZ C%%? QUAD <br />�aPL�4cE++�J7' <br />Y W <br />Crew to call SJ County Inspector 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 to excavate, construct and/or otherwise encroach on County Highway Right -of -Way on <br />the Norm Slde Of Grant Line Road approximately sso feet/mile west <br />of S Bird Rd Stockton by performing the following work (description of work): <br />Emergency pole replacement - pole was hit by car. <br />Work will commence on or after 4io�/2o�s <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 />TW MaMrn) <br />z <br />Signature of Applicant -Title <br />Y:IFORMS & TEMPLATESIENCROACHMENT PERMIT APPLICATION.dw (08/08) <br />12/05/19 <br />Date <br />