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APPLICATION FOR ENCROACHMENT PERMIT <br />PLEASE PRINT: <br />To <br />10/21/19 <br />San Joaquin County <br />Department of Public Works <br />PG&E PM 31364149 <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 />VVAT8@ PGE.COM <br />(Email Address) <br />Sketch (Detailed plans may be submitted) <br />JOB # <br />APN <br />EXP. DATE <br />VALIDj� <br />STREET <br />AREA <br />TYPE <br />FORMS <br />NOTES <br />736ot <br />mpole �e,�/Gccr+ien'l� <br />:: s <br />OFFICE USE ONLY <br />a_ REF # <br />CR # <br />Tit 12,0 <br />TO so DRIVEWAYS: <br />oGtA 9D. <br />QUAD <br />ti1e� /a/erns 4�% <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 East side of Bruella Rd approximately 7221 ee mile North <br />of Schmeidt Rd Lodi by performing the following work ( escription of work): <br />Replace pole and install a new pole 14' north <br />Work will commence on or after 11/15/19 - 05/01/20 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 Applicant -Title <br />Y:IFCRMS & TEMPLATESIENCROACHMENT PERMIT APPLICATICN.doc (00108) <br />10/21/19 <br />Date <br />