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APPLICATION FOR ENCROACHMENT PERMIT <br /> PLEASE PRINT: <br /> Date July 17,2015 OFFICE USE ONLY <br /> To: San Joaquin County JOB# Z.Q o Z REF# <br /> Department of Public Works APN CR# <br /> EXP.DATE <br /> Benjamin Serna-Group Delta VALID 7—X;_>-1 5 TO DRIVEWAYS: <br /> (Applicant Name) STREET <br /> AREA S QUAD C <br /> 505 14th Street,Suite 900 TYPE <br /> (Mailing Address) FORMS oyy'rf/ <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 feet/mile west/east <br /> of roadway centerline _, by performing the following work(description of work): <br /> Collect samples for hazardous materials analysis (asbestos,lead,etc.) from portions of the bridge including, <br /> but not limited to concrete expansiooin guard rail gaskets,mastics,and paint <br /> Work will commence on or about July 22,2015,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 /> -Senior Engineer July 17,2015 <br /> Signatdri of A icant-Title Date <br /> Izz <br /> EWU&SV WKMASTER.PSENCROACHMENTPERMfT APPLICATION DOC PID13) <br />