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STATE OFCALIFORNIA•DEPARTMENTOFTF' ;PORTATION Page 1 of 4 STANDARD ENCROACHMER. PERMIT APPLICATION .+ZIR CAlTRANS USE TR-0100 (REV.0712007) PERMITNO. Permission is requested to encroach on the Slate Highway right-of-way as follows: DISTICOIRTEIPM DD (Complete all BOXES (wrfte N/A if not appikabfel Pleage print single side 1 o— - u205- R 2:7 1.• Ta application Is not complete until all requirements have been approved. SIMPLEX STAMP 1. uNTY 2.ROUTE 13.POSTMILE 14 O I 1 b Joaquin 1 205 R2.71R4.9 ,�,f 4. DRESS OR STREET NAME 5.CITY 1 Q �r N 1�-210 5 Tracy 64MOSS STREET(Distance and direclion from silo) 7.PORTION OF RIGHT-OF-WAY DATE OF SIMPLE STA iP 3-200' South of Byron Road _�) , as y- 8 RK TO BE PERFORMED BY 9.EST.START DATE W.EST.COMPLE ON D TE =WN FORCES ❑ CONTRACTOR 3/3/2014 9/3/2014 1b'" MAX,DEPTH JAVG.DEPTH AVG.WIDTH LENGTH SURFACE TYPE �AVATfON n/a n/a n/a n/a n/a 12.EST.COST IN STATE HIGHWAY RIGHT-OF-WAY FUNDING SOURCE(S) n/a ❑FEDERAL 0STATE 0 LOCAL ❑ PRIVATE 13. PRODUCT TYPE DIAMETER VOLTAGE/PSIG 14.CALTRANS'PROJECTCODE PIPES n/a n/a n/a 10-OH9101 15. ❑ Double Permit Parent Permit Number Applicant's Reference Number f Utility Work Order Number 16. Have your plans been reviewed by another Caltrans branch? ® NO ❑ YES (If"YES") Who? 17. Completely describe work to be done within STATE highway rlght-of•way : Attach 6 complete sets of plans(folded to 85'x 11"),and any applicable specifications,calculations,maps,etc. All dimensions shall be In U.S.Customary(English)Units. Field work includes performing geotechnical explorations for the proposed bridge and for evaluating the pavement section. Three explorations will be conducted to a depth of 120' using 8" diameter augers. Two short cores/borings will be drilled to measure existing pavement section in the shoulder area (Cl and C2). Lane closure is not proposed. Shoulder work will be performed. If shoulder closure is required it will follow Caltrans traffic control plans and notification requirements. All excavations will be filled in with cement grout and the cuttings will be hauled off the site. 18.Is a city, county, or other agency Involved In the approval of this project? 10 YES (ff'YES",check type of project and allach environmental documentation and conditions of approval.) ❑COMMERCIAL DEVELOPMENT ❑BUILDING ❑GRADING ❑OTHER San Joaquin County and City Of Tracy ❑CATEGORICALLYEXEMPT ❑NEGATIVE DECLARATION ❑ENVIRONMENTAL IMPACT REPORT ❑OTHER Env.document completed&on file ❑ NO th"NO",please check Ore category below which best describes the project,and complete page 4 of this application.) ❑ DRIVEWAY OR ROAD APPROACH,RECONSTRUCTION,MAINTENANCE,OR RESURFACING ❑ FENCE ❑ PUBLIC UTILITY MODIFICATIONS,EXTENSIONS,HOOKUPS ❑ MAILBOX ❑ FLAGS,SIGNS,BANNERS,DECORATIONS,PARADES AND CELEBRATIONS ❑ EROSION CONTROL ❑ OTHER ❑ LANDSCAPING 19.Will this project cause a substantial change in the significance of a historical resource(45 years or older),or cultural resource? ❑YES ® NO (If'YES",provide a description) 20.Is this project on an existing highway or street where the activity involves removal of a scenic resource including a significant bee or stand of trees,a rock outcropping or a historic building?❑ YES m NO (if-YES",provide a description) 21.Is work being done on applicant's property? ❑ YES ❑ NO (If"YES",attach site and grading plans.) ADA NOTICE: For individuals with sensory disabilities,this document is available in ahemate formals.For information,call(916)654-46410,7TY 711,or write to Records and Forms Management,1130 N Sirecl,,11S—S9,Sacramento,CA 95314.