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:;TATE 0;CALIFORNIA•DEPARTMENT CF T'-dNSPOPTATION <br /> STANDARD ENCROACHMENT PERMIT APPLICATION Front <br /> -R 0100 (REV 10193) <br /> FOR CALTRANS USE <br /> PERMIT NO <br /> f'zrmtsslon Is requestro to rncruacn un Ing State Hluhwav r{Ittht ar 4Var 1094— ,/,5 ��� <br /> as rollows rCvmvlrtrsa arms NA it nm avvtrc.7vie I <br /> Application is not complete unnt all rcuurrea a[tacnm4.nts an tncludk d DISTICOATE PM f <br /> 10 <br /> I '-OCATIOti CrTY 2 COUNTY 3 ROUTE <br /> SIMPLEX STAMP <br /> + POST MILE 5 APPLICATION DATE I 6,aIDDRESS OR STREET NAME <br /> n I _ <br /> 77 o/ <br /> 7 CROSS STREET(Dlatance era cumparoq fro rel <br /> 6 PORTION Op RIGHT OF WAY DATE OF SIMPLEX STAMP <br /> fiw L�/U `oF� �rn �vs� 'v1 <br /> 9 WORK TO BE PERFORMED�B,YY 10 EST START DATE 1 EST COMPLETION DATE 12 EST COST IN STATE RrW <br /> C3 OWN FORCES !�CONTRACTOR 12/15/94 12/15/94 $3 500 <br /> 13 MAX DEAVG DEPTH 15 AVG WIDTH 16 LENGTH 17 SURFACE TYPE <br /> EXCAVATIONEXCAVATIONN/A PTH 1a M /A N /A <br /> PIPES10 TYPE 19 DIAMETER 20 VOLTAGE/KPA 21 PRODUCT <br /> N/A V A ti <br /> 22 FULLY DESCRIBE WORK WITHIN STATE R/W Arracn comalete oranS tmrnrmum 5 sets folded 21 59 centimeter X 27 94 centimeter(b 112 X 1 <br /> Pecs calCS maps arc if aaP11Cab/e <br /> See attacnment 1 <br /> 23 is any worit being done en applicant's property? O n g o i ng g r o u n d w a ter m o n t 1 or i ng (Z YES C] NO <br /> (!1'YES',brteny daacribo and ansch ate and gm,*ng vilma l and s o i l /groundwater treatment <br /> 24 Is a city,county,or other egeney mvoived on the enwonmentae approvailI County well permit required (to N obtt <br /> XJ YES (Ch m awNw mw opm�ngexam aea,anwy~ ❑ EXEMPT ❑N.O. ❑EIR <br /> Cl NO (Cha*ow ow wcrwwl <br /> ❑ SURVEY ❑ FENCE ❑ PAAAOE&CELEBRATIONS ❑ MAWTENANCE OF EXISTING <br /> ❑ FLAGS SIGNS BANK@tris, ❑ SINGLE FAMILY OWEUANQ [:3 comAupdTY ANTENNA TV SYSTEM LINO <br /> DECORATIONS ORIVEWAY ❑ REGUILATORYWARNING <br /> ❑ TEMPORARY SIGNALS ❑ AEMOVAL•AEPLACEMENT OF ❑ EROSION CONTROL INFORMATION 911GUS <br /> C] PUBLIC UTILITY MOOtFICATON3 <br /> OISTINCT1YE RGAOwAY MARKMOS ClIC <br /> AGRMTUAAL APPROACH 13 MODIFICATION OF TRAFFIC <br /> CONTROL SYSTEMS <br /> EXTENSIONS HOOKUPS ❑ DITCH PAVING, C3MAINTENANCE RECONSTRUCTION OR <br /> RESURFACING OF A DRIVEWAY OR ROAD ❑ MOVIE,TV FILMING <br /> ❑ sioEyitALKicturrERs ❑ MAILBOX APPROACH <br /> ❑ NONE OF THE ABOVE gaws 0wgwW wap&M*1m"Pma a Imm nIr Romw CIA=I <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 in accordance with Caltrans rules and regulations subject to <br /> inspection and approval. <br /> 2S.ORGANtZATIDN OR APPLICANT NAME(PrW or rW&) 26 BUSINESS PHONE <br /> ARCO Products Company (415) 571-2468 <br /> a 27 ARCHITECT ENGINEER OR PROJECT MANAGER NAME(PrN1t or Type) 26 BUSINESS PHONE <br /> Kyle Christie - - 415 ) 571- <br /> 29 BUSINESS ADDRESS(&=tWeCMyentllp CodR) <br /> P 0. Box 5811 , San Mateo CA 94402 <br /> 30 AU 31.PRINT OR TYPE NAME 32.TITM23.DATE <br /> Kyle Christie Environ. Engineer et 9 y <br /> FM 14M M <br />