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APPLICATION FOR ENCROACHMENT PERMIT <br />PLEASE PRINT: <br />Date 11/12/19 <br />To: San Joaquin County <br />Department of Public Works <br />PG&E PM 35115712 <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 />p�-4 REF # <br />I A CR # <br />7/11z0 <br />20 9 TO 7 ZD DRIVEWAYS: <br />MjAce Ayc . <br />oc�t. tiw QUAD 11SP <br />AkQA& jAIMk <br />h/ <br />r A� <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 South side of E Miner Ave approximately 223' ee mile West <br />of N Broadway Ave I Stockton by performing the following work ( escription of work): <br />Remove overhead service wire. All overhead work <br />Work will commence on or after 12/20/19 - 06/15/20 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 Appiicant •Title <br />Y:IPORMS 8 TEMPLATESIENCRCACNMENi PERMIT APPLICATION.doc (08108) <br />11/12/19 <br />