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<br /> STANDARD ENCROACF; E6 PERMIT APPLICATION •
<br /> PART A
<br /> TR-0100 (REV.6/2000) FO-- ��� E
<br /> Permission Is requested to encroach on the State Highway Right of PERMIT NO.
<br /> Wayasfollows:(Comp/eteallitems:NAifnotapplicable.)
<br /> Application Is not complete until all required attachments are Included. DIST/CO/RTE/PM
<br /> I.COUNTY 2.ROUTE 3.POSTMILE SIMPLEX STAMP
<br /> c. Joe ;. -Z-5
<br /> 4.ADDRESS OR STR ET NAME 5.CITY 1
<br /> X55 oA.f� 5o,. J o _tea 5'/c, �GT
<br /> S.CROSS STREET(Distance and direction from sit) 7.FORT ON OF RIGHT OF WAY
<br /> r e„ 'I,(- e, oc.r, d 0C S.
<br /> S.WORK TO BE PERFORMED BY S.EST.ST DATE 10.EST.COMPLETION
<br /> DATE OF SIMPLEX STAMP
<br /> ❑OWN FORCES
<br /> CONTRACTOR A 2eo 3 DA's 1 7t7tL1
<br /> 1.MAX.DEPTH Z. AVG.DEPTH 13.AVG.WIDTH 14.LENGTH
<br /> EXCAVATION yy 16.SURFACE TYPE 1 COST IN STATE RAN
<br /> ^- o yo I o d { 10 , s
<br /> r,, a PRODUCT
<br /> s oao
<br /> 17.TYPE 19.DIAMETER 19.VOLTAGE/PSIG 20.PRODUCT
<br /> PIPES P V G
<br /> Zorn ,l, It
<br /> 21.FULLY DESCRIBE WORK WITHIN STATE R/W(additional space on reverse side if needed): Attach complete plans(minimum 5
<br /> sets folded 8.5"X 11" [216 mm X 2/$0 m—mr�.�)specs,talcs,maps,etc.,if appli �ble.
<br /> y'rzak..N�rL�..v-e. {-...o�.�i-i�/ L✓jG [ll %n �/�(c...� G�.¢+c o/I`/...aa c�..P/-'� -
<br /> 6os...d • F/cPt".y� Ot"V�i4..-,p � LGS 7' LJ" a�� bn.:". i'r"c�>< Qij✓G /.. Jt"oclG7'p�,
<br /> ar't'
<br /> L-,r ^ off nee�lfo(,e S� �orpCv, f//fro 11c, �c L��l¢hP��( ac tyo aceesj
<br /> L e-i6/S �4..Y-e�l i.. l�e tL. f4�p ro caL[ecV �'ror..,.�l.,tl'G, 54•�,lp�
<br /> t,/ Pcr,,..;7`" f�' j0o3 - (SSV— oz3 S
<br /> YOUR OWN REFERENCE NO. / 5 Has any other Caltrans Department reviewed your plans? YES
<br /> ® � NO
<br /> 22.Is any work being done on applicant's property? YES )R NO (If"YES,"briefly describe in section R21,and attach sne
<br /> and grading plans.)
<br /> 23.Is a city,county,or other agency involved in the environmental approval?
<br /> ❑ YES (Check documentatton type and attach appmved copy) ❑ CATEGORICALLY EXEMPT ❑N.D. ❑EIR
<br /> 1WNO (Check the categorybelow In section 23s,which describes the pr*cg
<br /> 23 a. ❑FLAGS,SIGNS,BANNERS, ❑CONSTRUCTION/MODIFICATION OF ❑ CONSTRUCTION,RECONSTRUCTION,MAINTENANCE,OR
<br /> DECORATIONS,PARADES AND SIGNALS OR ANY OTHER TRAFFIC CONTROL RESURFACING OF A DRIVEWAY OR ROAD APPROACH
<br /> CELEBRATIONS SYSTEMS AND DEVICES,INCLUDING
<br /> ON OR REPLACEMENT OF ROADWAY DEVICES OR
<br /> ❑DITCH PAVING ADDITION OF NEW ELEMENTS. ❑MARKINGS S((GLARE SCREEN,BARRIER.LIGHTING,STRIPING,
<br /> ❑FENCE ❑ PUBLIC UTILITY MODIFICATIONS, MARKERS ETC.)
<br /> ❑MAILBOX EXTENTIONS,HOOKUPS ❑ MOVIE,TV FILMING
<br /> ❑SIDEWALKS/GUTTERS ❑ EROSION CONTROL
<br /> ❑REPAIR/MAINTENANCE OF EXISTING HIGHWAYS ❑ SURVEY
<br /> 'NONE OF THE ABOVE IYpo/ect cannot be described in above cetepow,raryest epplketio Part 8 born th Permit ON-..)
<br /> 23 b
<br /> END!
<br /> this pr Jed taus a substantial change in the significance of a historical resource? "
<br /> YES ® NO thYES,"request application Pah"B"from
<br /> the Permit Once)
<br /> 23c. Is this project on an eXisting highway or street where the activity involves removal of a scenic resource including a stand of trees,a rock oulcroppng or
<br /> a historic building? ❑ YES RNO (If"YES,"request application Part"B"from the Permit Once)
<br /> The undersigned agrees and understands that a permit can be denied or a bond required for non-payment of prior
<br /> or present permit fees, that the work will be done in accordance with Caltrans rules and regulations subject to
<br /> inspection and approval,and that permit fees may still be due when an application is withdrawn or denied, and that
<br /> a denial may be appealed in accordance with California Streets and Highways Code, Section 671.5.
<br /> 24.ORGANIZATION OR APPLICANT NAME(Print or Type) 25.BUSINESS PHONE
<br /> 26.ARCHITECT,ENGINEER OR PROJECT MANAGER NAME(Print or Type) 27.BUSINESS PHONE
<br /> 28.BUSINESS ADDRESS(include City and Zip Code)
<br /> 29,AUTHORIZED SIGNATURE 30.PRINT OR TYPE NAME 31.TITLE 32,DATE
<br /> W91 1403 M
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