Laserfiche WebLink
STATE OF CALIFORNIA•DEPARTI 1 T OF TRANSPORTATION <br /> STANDARD ENCROACt&AENT PERMIT APPLICATION <br /> TR-0100 (REV. 10/93) Front <br /> FOR CALTRANS USE <br /> Permission is requested to encroach on the State Highway Right of Way PERMIT NO. / <br /> 6 <br /> as follows: (Complete all items:NA if not applicable.) 1094- - v/ <br /> Application is not complete until all required attachments are included. DIST/CO/RTE/PM <br /> 1.LOCATION:CITY 2.COUNTY _T1 <br /> G, 'S - 3 1,4 5 <br /> 3.ROUTE SIMPLEX STAMP <br /> Vi CL <br /> 4.POST MILE j6.APPLICATION DATE 6 DRESS OR STREET NAME <br /> 7.CROSS STREET(Distance and redlo bore te)., <br /> 1_17 �l Q <br /> 8.PORTION RIGHT OF WAY <br /> � fi�1.1 ,., r _ r-,) DATE <br /> t/1 <br /> / DATE OF SIMPLEX STAMP <br /> 9.WORK TO BE PERFORMED BY 10TART DATE 1.EST.COMPLETION DATE 12. EST,COST IN STATE R/W <br /> ❑OWN FORCES {/�,CONTRACTOR 1 /94 12/15/94 3 500 <br /> EXCAVATION 13.MAX.DEPTH 14. AVG.DEPTH 15.AVG.WIDTH 16.LENGTH 17.SURFACE TYPE <br /> N A N A N/ANZA N/A <br /> PIPES <br /> 18.TYPE ..N A 19.DIAMETER N A NZA <br /> PA 20.VOLTAGE/K 21.PRODUCT <br /> 22. FULLY DESCRIBE WORK WITHIN STATE R/W:Attach complete plans(minimum 5 sets folded 21.59 centimeter 27.94 centimeter(8 1/2X 11')) <br /> specs, calcs,maps, etc.,if applicable. <br /> See attachment 1 <br /> 23.Is any work being done on applicant's property? O n g o i ng g r o u n d w a ter m o n t i or i n g [0 YES 0 NO <br /> (If'YES',briefly 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 /> y2-44..Is a city,county,or other agency involved in the environmental approval? <br /> ,yp, YES County well permit required (to be obtain, <br /> (Chck documentefbn typee and attachapproved copy) ❑ EXEMPT ❑N.D. ❑EIR <br /> ❑ NO (Check the category below which describes the project) <br /> ❑ SURVEY ❑ FENCE ❑ PARADES,CELEBRATIONS ❑ MAINTENANCE OF EXISTING <br /> ❑ FLAGS,SIGNS,BANNERS, ❑ SINGLE FAMILY DWELLING ❑ COMMUNITY ANTENNA TV SYSTEM LANDSCAPING <br /> DECORATIONS DRIVEWAY <br /> ❑ REGULATORY WARNING, <br /> ❑ TEMPORARY SIGNALS ❑ REMOVAL-REPLACEMENT OF ❑ EROSION CONTROL INFORMATION SIGNS <br /> ❑ PUBLIC UTILITY MODIFICATIONS, DISTINCTIVE ROADWAY MARKINGS ❑ AGRICULTURAL APPROACH ❑ MODIFICATION OF TRAFFIC <br /> EXTENSIONS,HOOKUPS ❑ DITCH PAVINGCONTROL SYSTEMS <br /> ❑ MAINTENANCE,RECONSTRUCTION,OR <br /> ❑ SIDEWALK/GUTTERS ❑ MAILBOX RESURFACING OF A DRIVEWAY OR ROAD ❑ MOVIE,TV FILMING <br /> E] NONE NONE OF THE ABOVE(If pro)ect cannot be described in above categories,request application Part a from the Permit 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 Company415 571-2468 <br /> 27.ARCHITECT,ENGINEER OR PROJECT MANAGER NAME(Print or Type) 28.BUSINESS PHONE <br /> Kyle Christie - 415 571-24Fcs <br /> 29.BUSINESS ADDRESS{Include C/ry and ZQ Code) <br /> P. 0. Box 5811 San Mateo CA 94402 <br /> 30.AU ZED I 31.PRINT OR TYPE NAME 32.TITLE <br /> 33.DATE <br /> Kyle Christie Environ. Engineer It q qy <br /> FM 1a(191J <br />