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ITATE OF CALIFORNIA•DEPARTMENT OF TR. .'ORTATION Page 1 TANDARD ENCROACHMENT PERMIT APPLICATION RT A 100 (REV.8/97) 1=#�.Ri�A47RA1V5� Permission is requested to encroach on the State Highway Right of PERMIT NO. Way as follows: (Complete all items:NA if not applicable.) DISTICOfRTE/PM Application is not complete until all required attachments are included. 1.COUNTY 2.ROUTE 3.POSTMILE SIMPLEX STAMP San Joaquin 4 ,.ADDRESS OR STREET NAME 5•CITY Lafayette Street S'tocktori 8.CROSS STREET(Distance and direction from site) 7.PORTION OF RIGHT OF WAY California Street B.WORK TO BE PERFORMED BY 9.EST.START DATE 10.EST.COMPLETION DATE OF SIMPLEX STAMP DATE OWN FORCES ❑ CONTRACTOR 1.MAX.DEPTH 2. AVG.DEPTH 3.AVG.WIDTH 14.LENGTH 15.SURFACE TYPE 16. EST.COST INSTATE WIN EXCAVATION 8 0 1 2" d i a AC 17.TYPE 19.DIAMETER 1 S.VOLTAGE/PS1G 217.PRODUCT PIPES None 21.FULLY DESCRIBE WORK WITHIN STATE R/W(additional space on reverse side if needed): Attach complete plans(minimum 5 sets folded 21.6 centimeter X 28 centimenter(8.5"X 11'1)specs,calcs,maps,etc.,if applicable. See attached drawing for -location of CPT Boring with grout backfill - YOUR ackfillYOUR OWN REFERENCE NO. 2 1 1 1 Has any other Caltrans Department reviewed your plans? ❑ YES ff] NO (If'YES,"briefly describe in section N21,and attach site NO 22.Is any work being done on applicant's property? ❑ YES ❑ and grading plans.) 23.is a city,county,or other agency involved in the environmental approval? El YES (Check documentation type and attach approved copy) C] CATEGORICALLY EXEMPT ❑N.D. ❑E1R ❑ NO (Check the category below in section 23a,which describes the pro)ea) 23 IL ❑ FLAGS,SIGNS.BANNERS. ❑CONSTRUCTION 1 MODIFICATION OF CONSTRUCTION.RECONSTRUCTION,MAINTENANCE.OR DECORATIONS,PARADES AND SIGNALS OR ANY OTHER TRAFFIC CONTROL RESURFACING OF A DRIVEWAY OR ROAD APPROACH CELEBRATIONS SYSTEMS AND DEVICES,INCLUDING ❑ ADDITION OR REPLACEMENT OF ROADWAY DEVICES OR DITCH PAVING ADDITION OF NEW ELEMENTS. MARKINGS(GLARE SCREEN,BARRIER.LIGHTING,STRIPING, PUBLIC UTILITY MODIFICATIONS, MARKERS,ETC.) ❑FENCE E] PUBLIC HOOKUPS ❑ MOVIE,TV FILMING ❑MAILBOX ❑ EROSION CONTROL ❑SIDEWALKS/GUTTERS ❑ SURVEY ❑REPAIR/MAINTENANCE OF EXISTING HIGHWAYS Geotechnical Borin ❑NONE OF THE ABOVE(l1 project cannotbe described in a1lova caregarss request application Part B from Me PermN 011ice.) g 23 b. Does this project cause a substantial change in the significance of a historical resource? [:] YES ® NO (the Perif mit Ot {ioe)'request application Part"B"from 23 c. Is this project on an existing highway or street where the activity involves removal of a scenic resource including a stared of trees,a rock outcroppng or a historic budding? YES ® NO (it'YES,-request application Pan 1011 from the Permit Office) permit can be dented or a band required for non-payment of prior The undersigned agrees and understands that a or present permit fees, that the work will be done In accordance with Caltrans rules and regulations subject to inspection and approval,and that permit fees may still be due when an application Is withdrawn or denied.and that a denial may be appealed In accordance with California Streets and Highways Code, Section 677.5. 24.ORGANIZATION OR APPLICANT NAME(Print or Type) 25.BUSINESS PHONE Michael & Sharon 01 ' Jkt- 26.ARCHITECT,ENGINEER OR PROJECT MANAGER NAME(Print or Type) Foo ' 28.8USINESS ADDRESS(lndude City and Z ode) 127 3 Lodi C — 32.DATE 29.AU E SIGN AT 30.PRINT OR TYPE NAME 31.TI1 LE Ervin Rifenburg Civil Engin 11/11/99 FM 91 1403 M i f