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APPLICATION FOR ENCROACHMENT PERMIT <br /> PLEASE PRINT: <br /> Date 6/26/15 OFFICE USE ONLY <br /> To: San Joaquin County JOB# 11o005, REF# <br /> Department of Public Works APN CR# <br /> EXP.DATE 9-(-($ <br /> Cardno ATC VALID -1 S' TO DRIVEWAYS: <br /> (Applicant Name) STREET <br /> AREA S QUAD <br /> 1117 Lone Palm Ave. TYPE <br /> (Mailing Address) FORMS <br /> NOTES <br /> Modesto, CA 95351 <br /> (City,State,Zip Code) <br /> (209)579-2221 <br /> (Area Code-Telephone Number) <br /> Sketch(Detailed plans may be submitted) <br /> Well abandonment activities in the county's right-of-way. Wells MW-7C, and MW-12B/C are to be <br /> destroyed. <br /> Asphalt in roadway will be restored in compliance with R29 specifications. <br /> See figure - Traffic control plan for location of wells and lane closure. <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 North Wilson way approximately soo feet/mile feet <br /> of Wilson way and , sanguinetti Lane , by performing the following work(description of work): <br /> Access groundwater monitoring wells for well abandonment.The wells are within the County of San Joaquin's maintained roadways-two within <br /> Sanguinetti Lane,MW-12B/C,and one within North Wilson Way,MW-7C. <br /> Work will commence on or about JULY 1, 2015 for approximately 30 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 /> Edwin Vandegrift <br /> 6/26/15 <br /> Signature of Applicant-.Title Date <br /> EiPU&SVWKIMASTERPSIENCROACHMENTPERMfr APPLICATION.DOC (01/08) <br />