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ttpatec PERMIT NUMBER: <br /> CITY OF MANTECA <br /> ENCROACHMENT PERMIT FORM <br /> Mailing Address: Phone (209)456-8580 <br /> Community Development Department <br /> 1001 W. Center St., Suite. C Email engpermits@ci.manteca.ca•us <br /> Manteca, CA 95337 <br /> COMPLETE ITEMS 1 THORUGH 5 AND WRITE INITIALS ON PAGE 2 <br /> 1. PROJECT INFORMATION 5. PERMITTEE'S SIGNATURE <br /> Project Name SR99-SR120 Interchange Please read this permit carefully. Keep at the work site.To arrange <br /> See attached maps for an inspection,call(209)639-5964 or(209)923-0528 at least 48 <br /> Address or APN : p hours prior to construction- <br /> Project Location See attached maps <br /> This permit is to be strictly construed and no work, other than that <br /> specifically mentioned in this permit,is hereby authorized. <br /> 2. PERMITTEE INFORMATION <br /> Contractor Name : Blackburn Consulting <br /> Phone (91 6)375-8706 X — <br /> PE TTEE'S SIGNATURE DATE <br /> E-mail danielc@blackbumconsulting.com <br /> License Number <br /> Business Address: 2491 Boatman Ave,west Sacramento,95691 APPROVED(Yes/No) <br /> License ✓ <br /> 3. SCOPE OF WORK Insurance <br /> _Dri"_horiws r—annging f_rorn-5 tcL80-feet_tiee� Traffic Control Plan <br /> for geotech soil samples. 1 boring per location <br /> shown on map. Holes will be 2"-6" in diameter. Monument Preservation <br /> Moratorium <br /> 4. WORK DETAILS General Provisions/City Notes <br /> Microsurfacing/Cape Seal Required? <br /> 'rentative Start Date March 4, 2019 Fee Required$ ��� Qa ►� <br /> Tentative End Date March 18, 2019 <br /> -- - ENQIrV •EIN . <br /> Total Working days requested 4,,. _ <br /> O TRENCH X A 45w- <br /> Total Length(s)(ft): RECOMMENDED FOR APPROVAL DATE—�--__--__e_- <br /> Maximum Depth(s)(ft): <br /> WORK COMPLETED <br /> 0 CURB/GUTTER/SIDEWALK REPAIR X <br /> INSPECTOR DATE <br /> Total Repair Length(ft): _ _ Permit Not Valid Unless Executed by the City Engineer or an <br /> authorized agent. <br /> 5-borings-wW--be-aduance"tb-a-brill-rig,--l..utrith.a-CP—T rig,ancL2_with_hand-auger_equipment,-B1, <br /> B2, and CPT 1 will be 80'deep.The rest will be 5-10'deep. <br /> n:.roachment Penna!orm August 2018 <br /> Page t of 2 <br />