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PLEASE PRINT: <br />Date 11/15/19 <br />To; <br />'"' '' San Joaquin County <br />Department of Public Works <br />AN JOA01JIN COUNTY <br />APPLICATION FOR ENCROACHMENT PERMIT2019 NOV I PM I:2 <br />PUot PM 43821448 <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 SE` NL'Y` <br />',1���a' REF # <br />CR # <br />7,0 <br />J21looliq T6 61 z0 DRIVEWAYS: <br />nZwj R <br />QUAD /V6 <br />t, " <br />p,✓1,I <br />S eci <br />Crew 'to call SJ County Inspector at (209) 953-742'1 d`ai�h io �,� hours'K��������°� work starfis. <br />When calling, crew shall request "rain clearance" for any work during winter months <br />November thro � IIS l o �V <br />The undersigned hereby applies for permission to excavate, construct and/or otherwise encroach on County Highway Right -of -Way on <br />the West side of N Jack Tone Rd approximately 1 200' ee mile South <br />of E Victor Rd Lodi by performing the following work ( escription of work); <br />Replace conductor board on existing pole. *ALL OVERHEAD WORK <br />Work will commence on or after 12/20/19 - 06/5/20 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 App'Cicant -Title <br />Y:IFCRMS 6 TEMPLATESIENCRCACHMENT PERMIT APPLICATION.doo (08108) <br />11/15/19 <br />Date <br />