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PZ001 and PZ002 <br /> APPLICATION FOR ENCROACHMENT PERMIT <br /> PLEASE PRINT: <br /> Date 18 December 2017 OFFICE USE ONLY <br /> To: San Joaquin County JOB# ( ( O 0 (� 5 REF# <br /> Department of Public Works APN CR# <br /> EXP.DATE - - ( S _/ <br /> Ahtna Environmental, Inc. - Scott Thompson VALID 4--(g TO /,C�_ DRIVEWAYS: <br /> (Applicant Name) STREET <br /> AREA QUAD <br /> 2255 Contra Costa Blvd Suite 312 TYPE r ; <br /> (Mailing Address) FORMS2 <br /> NOTES 7� <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 N and S side of Fisk Rd approximately 360' and 2 050' feet/mile W <br /> of Airport Rd by performing the following work(description of work): <br /> Abandonment of two(2)groundwater piezometers by pressure grouting under permit from San Joaquin County Environmental Health Dept. <br /> The two piezometers are identified as follows: <br /> PZ001 is located on the N side of Fisk Rd,4'from the pavement edge, on the upaved shoulder approximately 360' W of Airport Rd. <br /> PZ002 is located on the S side of Fisk Rd, 8.5'from the pavement edge, on the upaved shoulder approximately 2000' W of Airport Rd. <br /> Both piezometers are constructed of 1"PVC and extend to approximately 30'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 /> 18 December 2017 <br /> Signature of Applicant-Title Date <br /> Y:IFORMS 6 TEMPLATESIENCROACRNENT PERMIT APPLICATICN dw(0110) <br />