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PLEASE PRINT: <br />APPLICATION FOR ENCROACHMENT PERMIT <br />Date 10-30-19 <br />To; San Joaquin County <br />Department of Public Works <br />PG&E <br />(Applicant Name) <br />4155 E Childs Ave <br />(Mailing Address) <br />Merced, CA, 95340 <br />(City, State, Zip Code) <br />408-605-6657 <br />(Area Code •Telephone Number) <br />DQHN@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 />FORMSS.5 <br />NOTES <br />OFFICE USE ONLY <br />73W6o 4 REF '# <br />_ CR # <br />! <br />To / I zo <br />Ai 2,euor 6Iia <br />11&ArMcGA QUAD S W <br />ALL /4461w4S 2 <br />f <br />'C CL • 11w�S " <br />DRIVEWAYS: <br />` <br />AXe7 <br />Crew to call SJ County Inspector at (209) 953-7421 48 to 72 hours before work stacks. <br />When calling, crew shall request "rain clearance" for any work during winter months <br />November through March t <br />The undersigned hereby applies for permission fo excavate, construct and/or otherwise encroach on County Highway Right -of --Way on <br />the North &East side of Airport Way .approximately 3,525 ee mile <br />of Kasson rd , by performing the following work ( escription of work): <br />(ECDA investigation dig) Excavate/expose to inspect pipeline perform repairs as needed <br />PM#84008924 <br />Work will commence on or after <br />forapproximately <br />days. <br />I, the undersigned, certify chat I am the owner of the respective properly, of am qualified to represent the ownerantl agree to tlo the <br />vrork described above in accordance with the rules and regulations of San Joaquin County and subject to inspection and approval. <br />7��j"- /, &</ le, <br />Permit Facilitator 10/30/19 <br />Signature of App canf • Titie Date <br />YAFORW ATEWPLATES'EPMOAGAVIT KRO MUCATIWI dA Q:141) <br />