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APPLICATION FOR ENCROACHMENT PERMIT <br /> PLEASE PRINT: <br /> Date JUNE 4, 2012 OFFICE USE ONLY <br /> To: San Joaquin County JOB# REF# <br /> Department of Public Works APN <br /> EXP.DATE ! lZ <br /> CITY OF RIVERBANK, LAURA GRAYBILL VALID / Z TO Z2-DRIVEWAYS: <br /> (Applicant Name) STREET * 77-A r-g� P_D, <br /> AREA QUAD $E <br /> 6707 THIRD STREET TYPE p4r4 <br /> (Mailing Address) FORMS -L5' <br /> NOTES <br /> RIVERBANK, CA 95367 <br /> (City,State,Zip Code) <br /> 209-863-7155 <br /> (Area Code-Telephone Number) <br /> Sketch(Detailed plans may be submitted) <br /> SEE ATTACHED EXHIBIT "A" , EXHIBIT "B" AND EXHIBIT "C" . <br /> The undersigned hereby applies for permission to excavate,construct and/or otherwise e roach on County Highway Right-of-Way on <br /> the WEST side of SANTA FE ROAD approximately 2, 650 FEET feet/mile NW <br /> Of THE CL INTESECTION OF SANTA FE RQAD AND HENRY ROAD by performing the following work(description of work): <br /> INSTALL A NEW GROUNDWATER MONITORING WELL WITH PROTECTIVE SURFACE CASING. BOREHOLE <br /> DIAMETER TO BE 8" , DEPTH TO BE +/- 10 ' , CASING DIAMETER TO BE 2". OF TYPE ASTM F480 <br /> SCHEDULE 40 PVC (SEE EXHIBITS "B" AND "C" FOR PARTICULARS) . WORK TO BE PERFORMED <br /> BY A DRILLING CONTRACTOR. <br /> Work will commence on or about AUGUST 2012 for approximately 3 DAYS days. <br /> I,the undersigned,certify that I am the owner of the respective property,or am qualified to represent the owner and agree to do the <br /> work described above in accordance with the rules and regulations of San Joaquin County and subject to inspection and approval. <br /> 11 , 'Y�C;: PC'I P"Jur, <br /> Si" ature of licant-Title Date <br /> E:IPU&SV.WKVMSTERPSIENCROACHMENT PERMIT APPLICATION.DOC(OMB) <br />