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r ' <br /> 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 QR <br /> EXP.DATE ! l2 <br /> CITY OF RIVERBANK, LAURA GRAYBILL VALID TO f/nDRIVEWAYS: <br /> (Applicant Name) STREET iKeA - ,; <br /> 6707 THIRD STREET AREA QUAD $gTYPE AW!W <br /> (Mailing Address) FORMS <br /> RIVERBANK, CA 95367 NOTES <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 <br /> approximately 2, 650 FEET feet/mile NW <br /> Of THE CL INTESECTION OF SANTA FE ROAD 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 +/- 101 , CASING DIAMETER TO BE 211 OF TYPE' ASTM F480 <br /> SCHEDULE 40 PVC (SEE EXHIBI'T'S I'B" AND "C" FOR PARTICULARS) . WORK TO BE PERFORMED <br /> BY A DRILLING CONTRACTOR. <br /> Work will commence on or about AUGUST 2 012 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 /> rc e . nc�r� 61 it � 2 <br /> Si' ature of licant-Tit a Date <br /> E:IPUB-SV.WKWASTER.PSIENCROACHMENT PERMIT APPLICATION.DOC (01108) <br />