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APPLICATION FOR ENCROACHMENT PERMIT <br />PLEASE PRINT: <br />Date // 13 - <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 />WAT8(@PGE.00M <br />(Email Address) <br />may <br />JOB # <br />APN <br />EXP.DATE <br />VALID <br />STREET <br />AREA <br />TYPE <br />FORMS <br />NOTES <br />-7300152 REF# <br />SEE ATTACHED DRAWING <br />17719XV.Ivm <br />The undersi red hereby applies for permission to excavate, construct and/or otherwise encroach on County Highwa Right -of -Way on <br />the side of M%d d !�{ /d live approximately 3 k3 ee mile E <br />of C7 ra n a e Ave by performing the following work (description of work): <br />� f l�lj�� /✓II-fta//cerci �. ' ..(,k>lzv�Gr G cfivr-!� 1ePcs-fvr4�Un <br />Work will commence on or after ct h for approximately days. <br />I, the undersigned, certifythat 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 />2<�Q )//. "I <br />Signature Applicant itle Date <br />Y¢OPMS L TEMPWES NONOACNMENT PMAT AMWION ,&c (009) <br />