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PZ004 <br /> APPLICATION FOR ENCROACHMENT PERMIT <br /> PLEASE PRINT: <br /> Date 19 December 2017 OFFICE USE ONLY <br /> To: San Joaquin County JOB# j ��� S REF# <br /> Department of Public Works APN CR# <br /> EXP.DATE <br /> Ahtna Environmental, Inc. - Scott Thompson VALID 4 t9 TO DRIVEWAYS: <br /> (Applicant Name) STREET /L�(4f ih�P V ✓ <br /> AREA FQUA <br /> 2255 Contra Costa Blvd Suite 312 TYPE <br /> (Mailing Address) FORMS yv <br /> NOTES <br /> Pleasant Hill, CA 94523 <br /> (City, State,Zip Code) <br /> 925-239-6999 <br /> (Area Code-Telephone Number) <br /> sthompson@ahtna.net <br /> (Email Address) <br /> Sketch(Detailed plans may be submitted) <br /> See site-specific attachments, including project description, Site Location map and Site Plan. <br /> The undersigned hereby applies for permission to excavate,construct and/or otherwise encroach on County Highway Right-of-Way on <br /> the East side of McKinley Ave approximately 450' feet/mile North <br /> of E Krell Ln , by performing the following work(description of work): <br /> Abandonment of one(1)groundwater piezometer by pressure grouting under permit from San Joaquin County Env. Health Dept. <br /> The piezometer is constructed of 1"PVC and extends to approximately 33'below grade. <br /> Work will commence on or after January 1, 2018 for approximately 1 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 /> 19 December, 2017 <br /> Signature of Applicant-Title Date <br /> Y IFCRMS S TEMPLATESLNCROACKE`!T PERMIT APPLCAT ION da(0808 <br />