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tPPLICATION MK hNCROACHMENT PERMIT <br />I"LEASE PIo,INI': <br />Date 0 Aa A 0710 <br />To; San Joaquin County <br />Department of Public Works <br />Nathan Baker <br />(Applicant Name) <br />3318 Howard ST <br />(Mailing Address) <br />McClellan Park. CA 95652 <br />(City, State, Zip Code) <br />10-9911 <br />(Area Code • Telephone Number) <br />nathan.baker(@ <br />ponder-env. org <br />(Email Address) <br />Sketch (Detailed plans may be submitted) <br />OFFICE USE ONLY <br />JOB # 110005 REF # <br />APN CR # <br />EXP,DATE <br />VALID TO DRIVEWAYS, <br />STREET <br />AREA QUAD <br />TYPE <br />FORMS <br />NOTES <br />The undersigned hereby applies for permission to excavate, construct and/or otherwise encroach on County Highway Right -of -Way on <br />the west bound Slde Of 1=tench Camp Road approximately 2 miles feet/mile east <br />Of Jacktone Road by performing the following work (description of work); <br />Ponder environmental services will excavate contaminated soils into 20 yard bins for disposal,After San Joaquin county environmental <br />says the soil is no longer contaminated. Ponder will than start to back fill with CakTrans spec II,AB and compact the soil. <br />Work will commence on or after <br />days. <br />I, the undersigned, certify that I am the owner of the respective property, c <br />work described above in accordance with the rules and regulations of San <br />Signatut'e of Applicant •Title <br />Y:IFORMS & TEMPLATESIENCROACHNfNT PERMIT APPLICATION.doc (08108) <br />for approximately <br />one day <br />am qualified to represent the owner and agree to do the <br />Joaquin Coul qty and subject to inspection and approval. <br />Date <br />