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APPLICATION FOR ENCROACHMENT PERMIT <br />PLEASE PRINT: <br />Date OFFICE USE ONLY <br />To:San Joaquin County JOB #REF # <br />Department of Public Works APN CR # <br />EXP. DATE <br />VALID TO <br />DRIVEWAYS: <br />(Applicant Name)STREET * <br />AREA QUAD <br />* <br />TYPE * <br />(Mailing Address)FORMS <br />NOTES <br />(City, State, Zip Code) <br />(Area Code -Telephone Number) <br />(Email Address) <br />The undersigned hereby applies for permission to excavate, construct and/or otherwise encroach on County Highway Right-of-Way on <br />the ______________ side of ___________________________________ approximately ___________________ feet/mile _________ <br />of _______________________________________, ____________________, by performing the following work (description of work): <br />Work will commence on or after _____________________________________ for approximately ________________________ 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 Date <br />Y:\FORMS & TEMPLATES\ENCROACHMENT PERMIT APPLICATION.doc (08/08) <br />Sketch (Detailed plans may be submitted) <br />1524 N Carpenter Rd <br />Modesto, CA 95351 <br />209-857-0181 <br />(Area Code Telephone Number)(Area Code Telephone Number) <br />WAT8@PGE.COM <br />PM 35074401 <br />7/18/22 <br />7/18/22 <br />6 ________________________ days.________________________ days.months________________________ days.________________________ days.7/25/22 _____________________________ for approximately_____________________________ for approximately_____________________________ for approximately_____________________________ for approximately1/25/23_____________________________ for approximately_____________________________ for approximately <br />Bruella the ______________ side of ___________________________________ approximately ___________________ feet/mile _________the ______________ side of ___________________________________ approximately ___________________ feet/mile _________Rd the ______________ side of ___________________________________ approximately ___________________ feet/mile _________the ______________ side of ___________________________________ approximately ___________________ feet/mile _________and the ______________ side of ___________________________________ approximately ___________________ feet/mile _________the ______________ side of ___________________________________ approximately ___________________ feet/mile _________Cherry the ______________ side of ___________________________________ approximately ___________________ feet/mile _________the ______________ side of ___________________________________ approximately ___________________ feet/mile _________Rdthe ______________ side of ___________________________________ approximately ___________________ feet/mile _________the ______________ side of ___________________________________ approximately ___________________ feet/mile _________Lodi <br />LOC 1 - Pole replacement <br />LOC 2 - Replace cutout on existing pole. no ground disturbance <br />LOC 3 - Replace cutout on existing pole. no ground disturbance LOC 4 - in private property <br />730052 <br />7/25/2022 2/1/2023 <br />Bruella Rd. & Cherry Rd. <br />Lodi NE <br />Pole Replacement & Aerial Work <br />SS/WW <br />Special Conditions