Laserfiche WebLink
APPLICATION FOR ENCROACHMENT PERMIT <br /> PLEASE PRINT: <br /> Date May 12,2015 OFFICE USE ONLY <br /> To: San Joaquin County JOB# LZQQ Z G REF# <br /> Department of Public Works APN CR# <br /> EXP.DATE 15 <br /> Benjamin Serna- Group Delta VALID h -Z-(S TO - DRIVEWAYS: <br /> (Applicant Name) STREET L CU fotn 6edoj� <br /> AREA & — QUAD <br /> 505 14th Street,Suite 900 TYPE <br /> (Mailing Address) FORMS <br /> NOTES <br /> Oakland,CA 94612 <br /> (City,State,Zip Code) <br /> (510) 671-0012 <br /> (Area Code-Telephone Number) <br /> Sketch (Detailed plans may be submitted) <br /> The site is located at the Escalon Bellota Road Bridge over Littlejohns Creek about 1,650 feet south of State <br /> Highway 4 in Farmington. See attached site plan sketch. <br /> The undersigned hereby applies for permission to excavate, construct and/or otherwise encroach on County Highway Right-of-Way on <br /> the west and east side of Escalon Bellota Road approximately 30 ee ile west/east <br /> Of roadway centerline , by performing the following work(description of work): <br /> Drill and sample two soil borings for the San Joaquin County Escalon Bellota Road Bridge(29C-038) <br /> over Littlejohns Creek- Phase II Environmental Clearance and Final Design project. <br /> Work will commence on or about June 2,2015,for approximately 1 day. <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 /> �S�' <br /> - Senior Engineer May 12 2015 <br /> Signat r of A icant-Title Date <br /> E NU3SV WASTER PSIENCROACHMENT PERMR APPLICATION DOC (01r" <br />