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;TATE Or CALIFORNIA•OEPARTMENT CP Tr=ANS;ICP T ATION <br /> STANDARD ENCROACHMENT PERMIT APPLICATION Front <br /> `R-0100 fREV 10/931 <br /> FOR CALTRANS USE <br />• n I'ermission Is reRuestea to rncroacon the Stair HI>;hwav rclKht or 1,Vav PERMIT NOr��_ � V— <br /> Application <br /> as rollaws fComvrrreza nems NA it ntn avivicacte 1 Y <br /> Application is not complete until all reauirea attachments are IncludLd DISTrCQ'RTE PM <br /> - <br /> I LOCATION CITY ; Z COUNTY 3 ROUTE <br /> ) 5' -ss - 01.45 <br /> SIMPLEX STAMP <br /> 4 POST MILE 5 APPLICATION DATE 669DORESS OR STREET NAME <br /> Z- 2- <br /> �1 <br /> �� c� W,-r <br /> 7 CROSS STREET/DlstameanarivsalIro fro re1� <br /> �!V Q <br /> B PORTION 0#RIGHT OF WAYDATE OF SIMPLEX STAMP <br /> fiw Ib `O <br /> UFF <br /> vs <br /> � Z =vL� <br /> 9 WORK TO BE PERFORMED BY tO EST START DATE 1I 1 EST COMPLETION DATE 12 EST COST IN STATE RW <br /> ❑OWN FORCES CONTRACTOR 12/15/94 12/15/94 $3.500 <br /> EXCAVATION 13 MAX DEPTH 114 AVG DEPTH 15 AVG WIDTH 16 LENGTH 17 SURFACE TYPE <br /> N/A N! A N /A <br /> 18 TYPE 19 DIAMETER <br /> PIPES 20 VOLTAGE jKPA T21 PRODUCT <br /> N A iV A <br /> 22 FULLY DESCRIBE WORK WITHIN STATE R(W Attach comolete clans(minimum 5 sets folded 21 59 centimeter 27 94 centimeter(8 1/2 X <br /> specs talcs maps etc If applicable <br /> See attachment 1 <br /> 23 la any Work being done on apphennVe property? O n g o i n g g c o u n d w a t ex m o n t 1 o r I n g ® YES ❑ NO <br /> (If'YES',briefly describe and attach site and grading pians) a n d s o z I /g r o u n d w a t e r t r e a t m e n t <br /> 24 Ia a City,county,or odWr agency invotved to the environmenW approval? <br /> � <br /> YES (er,.e.e,,,r,,,,.,,,.I.,,, County well permit required {to be— <br /> obi <br /> MW 4Aaatt•PWa'd 00,') ❑ EXEMPT ❑N o ❑EIR <br /> ❑ NO (Checir&w a --Y m iG k .0W h d.*16"n.p VM0p <br /> SURVEY ❑ fENCE ❑ PARADES CELEBRATIONS 0 MAINTENANCE OF EXISTING <br /> ❑ FLAGS SIGNS BANNERSLANDSCAPING <br /> ❑ SINGLE FAMILY DWELLING ❑ COMMUNITY ANTENNA TV SYSTEM <br /> DECORATIONS DRIVEWAY <br /> REGULATORY <br /> C] TEMPORARY REMOVAL REPLACEMENT OF <br /> ARY SIGNALS ❑ EROSION CONTROL ❑ INFORMATION SIGNS <br /> ❑ <br /> PUBLIC UTILITY MODIFICATIONS <br /> DISTINCTIVE ROADWAY MARKINGS ❑ AGRICULTURAL APPROACH ❑ MOOIFICATION OF TRAFFIC EXTENSIONS HOOKUPS ❑ DITCH PAVING 0 MAINTENA14CE RECONSTRUCTION OR CONTROL SYSTEMS <br /> RESURFACING OF A DRIVEWAY OR ROAD C3 MOVIE TV FILMING <br /> ❑ SIDEWALK/GUTTERS ❑ MAILBOX APPROACH <br /> ❑ NONE OF THE ABOVE 1rI0m0`W adARW JI-de-00d n eftwe awrpe,ma nwmw&,~v„Pan a hom IM Pa mil Office) <br /> The undersigned agrees and understands that a permit can be dented or a bond required for non-payment of prior or <br /> present permit fees,and that the work will be done to accordance with Caltrans rules and regulations subject to <br /> inspection and approval. <br /> 2S ORGANIZATION OR APPLICANT NAME(Pnnr or Type) 28 BUSINESS PHONE <br /> ARCO Products Company 415 71- <br />• 27 ARCHITECT ENGINEER OR PROJECT MANAGER NAME(Pdht or Type) - 28 BUSINESS PHONE <br /> Kyle Christie - 415 571 -246a <br /> 29 BUSINESS ADDRESS(kx*fdo CNy and Z*7 Co*) <br /> P. 0 Box 5811 San Mateo. CA 94402 <br /> 30 AUMMDI 31 PRINT OR TYPE NAME 32.T1TUEDATE <br /> Kyle Christie Environ. Engineer Ir 9 qy <br /> FM 1403 M <br />