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,TATE OF CALIFORNIA- DEPARTMF',LT OF TRANSPORTATION <br /> y ,-_STANDARD ENCROACi.,,,ENT PERMIT APPLICATION .Io' Front <br /> TR-01 D0 (REV. 10/93) FOR CALTRANS USE _ <br /> PERMIT NO. <br /> Permission is requested to encroach on the State Highway night of Way aC�/t - <br /> as follows: (Completezli items:NA ifn[n appijn4 <br /> ble.) <br /> Application is not complete untli all required attachments are included. CO,ATE:PM <br /> 1.LOCATION:CITY 12.COUNTY 3.ROUTE SIMPLEX STAMP <br /> 4.POST MILE S.APPLICATION DATE 6 ADDRESS OR STREET NAME <br /> 7.CROSS STREET(Distance and direalo Iro te)� <br /> S.PORTION RIGHT OF WAY r DATE OF SIMPLEX STAMP <br /> �fiw� b rO Al F t=''i�r� C47s1 'vt/ <br /> 9.WORK TO BE PERFORMED BY 10.tST.START DATE fl.EST.COMPLETION DATE 12. EST.COST IN STATE RNV <br /> 13 OWN FORCES CONTRACTOR 12/15/94 12/15/94 :, ..,x.-. <br /> 13.MAX.DEPTH 14. AVG.DEPTH IS.AVG.WIDTH 16.LENGTH 1�.IS44RFACE TYPE <br /> EXCAVATIONN/A N/A N/A <br /> NZA N /A <br /> PIPES <br /> 18.TYPE 19.DIAMETER 20.VOLTAGE/KPA 21.PRODUCT <br /> N A N A <br /> 22.FULLY DESCRIBE WORK WITHIN STATE R/W:Attach complete plans(minimum 5 sets folded 21.59 centimeter X 27.94 centimeter(8 112X 11)) <br /> specs, talcs,maps,etc.,if applicable. <br /> See attachment 1 <br /> 23.Is any work being done on applicant's property? O n g o i n g g r o u n d w a t ex m o n t i o r i n g ® YES [:] NO <br /> ()f'YES',b6afly describe and attach site and grading plans.) a n d s o i l /g r o u n d w a t e r t r e a t m e n t <br /> 24.Is a city,county,or other agency involved in the environmental approval? <br /> y-�0. County well permit required (to be- <br /> obtain <br /> bYES (Chock dooumentahon type end erfeoh epproved coq) ❑ EXEMPT ❑N.D. ❑EIR <br /> ❑ NO (Chock the ce/egory below Much doe ,bx s the prgeco <br /> ❑ SURVEY ❑ FENCE ❑ PARADES,CELEBRATIONS ❑ MAINTENANCE OF EXISTING <br /> ❑ FLAGS.SIGNS,BANNERS, -❑ SINGLE FAMILY DWELLING ❑ COMMUNITY ANTENNA TV SYSTEM LANDSCAPING <br /> DECORATIONS DRIVEWAY ❑ REGULATORY WARNING. <br /> ❑ TEMPORARY SIGNALS ❑ REMOVAL-REPLACEMENT OF ❑ EROSION CONTROL INFORMATION SIGNS <br /> DISTINCTIVE ROADWAY MARKINGS ❑ AGRICULTURAL APPROACH ❑ MODIFICATION OF TRAFFIC <br /> ❑ PUBLIC UTILITY MODIFICATIONS, CONTROL SYSTEMS <br /> EXTENSIONS.HOOKUPS ❑ DITCH PAVING O MAINTENANCE,RECONSTRUCTION,OR <br /> RESURFACING OF A DRIVEWAY OR ROAD C] MOVIE,TV FILMING <br /> ❑ SIDEWALK/GUTTERS ❑ MAILBOX APPROACH <br /> ❑ NONE OF THE ABOVE(It ptojoa carrot be described in above categories•reavesY epphca/Wn Pert B from the Perrnt Office.) <br /> The undersigned agrees and understands that a permit can be denied or a bond required for non-payment of prior or <br /> present permit fees, and that the work will be done in accordance with Caltrans rules and regulations subject to <br /> inspection and approval. <br /> 25.ORGANIZATION OR APPLICANT NAME(Print or Type) 26.BUSINESS PHONE <br /> ARCO Products Company -L415) 571-2468 <br /> 27.ARCHITECT,ENGINEER OR PROJECT MANAGER NAME(Print or Type) 28.BUSINESS PHONE <br /> Kyle Christie - 415 571-2463 <br /> 29.BUSINESS ADDRESS(Include CltyanaZQ Code) <br /> P. 0. Box 5811 , San Mateo. CA 94402 <br /> 30.AU ZED I 31.PRINT OR TYPE NAME 32.TITLE 33.DATE <br /> Kyle Christie Environ. Engineer tl 9 qy <br /> FM 14111 M <br />