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APPLICATION FOR ENCROACHMENT PERMIT <br />PLEASE PRINT; <br />Date 11/26/19 <br />To: San Joaquin County <br />Department of Public Works <br />PG&E PM 43942324 <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 #7,3ov� <br />AFIN <br />EXP. DATE <br />VALID <br />STREET <br />AREA <br />TYPE <br />FORMS <br />NCITES <br />OFFICE USE ONLY <br />2- REF # <br />CR # <br />It 12wo <br />1 5 I Tb 21 z c DRIVEWAYS: <br />0 1:k&T•1E2. 12p <br />Low t QUAD <br />Zc 6C.E LbijCT SHaUGDE�* <br />/,✓,✓ -2`3 <br />6Giy4 G Go�tJ� /?�Drc�S �' <br />Crew to call SJ County Inspector at (209) 953-7421 �8 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 uhdersigned hereby applies for permission to excavate, construct and/or otherwise encroach on County Highway Right -of -Way on <br />the North side of W Peltier Rd approximately 9361 ee mile East <br />of N Devries Rd Lodi by performing the following work ( escription of work): <br />Install electric #5 Box <br />Work will commence on or after 1/5/20 - 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 />11/26/19 <br />Signature of Appiicant -Title Date <br />Y:IFORMS 6 TEMPLATESIENCROACNMENi PERMIT APPLICATI ON.dac (08108) <br />