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APPLICATION FOR ENCROACHMENT PERMIT <br />PLEASE PRINT: <br />Date /I /)-)- <br />To: San Joaquin County <br />Department of Public Works <br />PG&E <br />(Applicant Name) <br />4040 West Lane <br />(Mailing Address) <br />Stockton, CA. 95204 <br />(City, State, Zip Code) <br />(209) 409-2083 <br />(Area Code -Telephone Number) <br />WAT80)PGE.00M <br />(Email Address) <br />Sketch (Detailed plans may be submitted) <br />JOB # <br />APN <br />EXR DATE <br />VALID <br />STREET <br />AREA <br />TYPE <br />FORMS <br />NOTES <br />OFFICE USE ONL <br />7 1 605 2 REF # <br />SEE ATTACHED DRAWING <br />CR # <br />Z -l- IS <br />TO 2- <br />/ PT (CA <br />LWHN <br />PM # A2iL vr�� <br />DRIVEWAYS: <br />The undersigned hereby applies for permission to excavate, construct and/or otherwise encroa� obi god l> -Highway Right -of -Way on <br />the side of /t1 %d d (e �i e %{ AYe approximately ?a'S 3 mile E <br />of C7✓a n p e Ave 57Ii C cfpn , by performing the following work (description of work): <br />/I IIi cR� /Ecr /�, /rrltA//�e1 ®2 ' �,[ <! o G �ilkvo . Xe—sf�r4 7n <br />Work will commence on or after 1XIII for approximately days. <br />I, the undersigned, certify that I am the owner of the respective properly, 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 />2</ — 2 //Aa-1/� <br />Signature Applicant title Date <br />Y O RNIS 8 TEIMPLATE5ENCROACHINII ENT PERT IT APPUCAPONA-(00105) <br />