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APPLICATION FOR ENCROACHMENT PERMIT <br />PLEASE PRINT: <br />Date 4/10/18 <br />To: San Joaquin County <br />Department of Public Works <br />PG&E - Nicole Merritt _ <br />(Applicant Name) <br />6121 Bollinger Canyon Rd., BR I Z4D <br />(Mailing Address) <br />San Ramon, CA 94583 <br />(City, State, Zip Code) <br />925-244-3815 <br />(Area Code - Telephone Number) <br />N2MOna PGE.COM <br />(Email Address) <br />Sketch (Detailed plans may be submitted) <br />Se IE S;� IE -V (A <br />OFFICE USE ONLY <br />JOB # REF # <br />APN CR # <br />EXP. DATE <br />VALID _ TO DRIVEWAYS: <br />STREET <br />AREA QUAD <br />TYPF <br />FORMS <br />NOTES <br />The undersigned hereby applies for permission to excavate, construct and/or otherwise encroach on County Highway Right -of -Way on <br />the NORTH side of VV. Ripon Rd approximately 1,300' feet fee�mile west <br />of S. Union Rd , by performing the following work (description of work): <br />Fxravate 10" inch diamater pothole on pavement an rnxip mafely 1' font frnm Edge of Pavement R rnver with <br />metal lid (standard detail attached). <br />On dirt shoulder will excavate 4'x4' and 1?'x1' bench <br />Standard traffic contrnl for one lane_r-losw_e._ <br />Standards & specs attached. <br />Work will commence on or after 4/23/18 for approximately 30 days. <br />I, the undersigned, certii i 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 ounty and subject to inspection and approval. <br />Vlltj ) <br />fy <br />Signature of Applicant - Title Date <br />nmpjJa& ie.PLAlEStXCio.L:H'.v., F&vxrA_--Uc lo?i_(mq <br />