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<br />APPLICATION FOR ENCROACHIVlENT PERPmr
<br />PLEi\SE PRINT:
<br />OFFICE USE ONLY
<br />JOB#1/0 UO '>REF II
<br />APN CR#
<br />EXP.DATE '7 '/5 'Ib
<br />VALID ?,-2.liJ6 TO ;-/?-ib DRIVEWAYS:
<br />STREET •1f:;&mf:O fe'AREA T..'I.i{xL QUAD ,N kif •
<br />TYPE -Iv ,"11\(h .•
<br />FORMS \'7 \<1/111/.
<br />NOTES
<br />-.,
<br />To:San Joaquin Counly
<br />Department of Public Won(s
<br />li(~~\"I.(CJ\'l).\n ..,-<.-\~(iVI
<br />(Applicant iIJali1e)
<br />I ()Z f?{it,'~Ldl Vj~~c~_,_V_I~'e._
<br />(Mailir'Jg Aclclre;;s)
<br />----Ceiq-6-C~.q6 J (f)__
<br />(Cily,State,Zip Code)
<br />7...o~-67(.,.8106 /ZOtf-(;71-1..779
<br />(Area Code.Te(ephone Number)
<br />,
<br />Sketch (Detailed plans may be submiiled)
<br />"",~--'-------
<br />o i'l <;i~e ,k;lI (b)O;'1ttV I \i)<l,,-;.r if J fl ..l,,,-.le L•..•l.cl ..;.~'l.!~!~.''('''":l!t\I ~$1~,'1 1_vVU__'j;~rlt;-.;.:.f..Illh'vA ~_I ~~,..1•--------.--,-....-~---~--=r5---\7_--s.CJ••-_...--..-'oCD--:"'--V--q----__I
<br />~.,'-.-".--.(,?[~.\~;c•.....~o.'
<br />/--~"RiO Blanco Rd subject ;';;;::;m~::~:::::;-!'
<br />_seal from the centerline (or lane lin:)to the edge of the ~
<br />-----travelled way as per the San Joaqum County Trench Cut 1~1
<br />Policy.If the pavement is disturbed.on both sides ofthe L
<br />centerline (or adjacent lane),then the entire roadway (or i!
<br />affected lanes)shall be resurfaced.Contractor shall slurry e
<br />within 10 working days of permanent trench paving.Shoulder t~.
<br />areas shall be brought up to the finish grade as directed by
<br />the County.
<br />The und~rsigned.hereby applies f9r permission to excavate,construct andior olhelwise encroach on County High\'iqy Righl-ol-Way all
<br />Ihe I,Je s-\side of .(2.\()cnc...\(Ii IZ d approximately.2CGO'@iil1mile _{}",~11;/>'{
<br />of ",by performing the following work (desciiplion ofworl<):R,
<br />(-<I')l (-..-...C,-t'L\C '0 .:1\<.'...••.."c.._....;p'£:\
<br />-h"c,-".J.~.-••.Ire".:0;-i)-\'~'f
<br />,',,c<,,,(IS af \'\,~".~~o-j 'N.<Lv"a"c""\.1,,,
<br />Cal,G\..t'",S:"'Gt\t}\u-.nM"\A.l;('\,a.l1 NS'~c;o<:\.1 30X.3'
<br />Nork will commence on or about~,3~'_7_'-_l_()_lc~',for approximately days.
<br />,the undersigned,certify that I am the owner of lhe respeclive property,or am qualified to represent the oWller and agree to do lhe.
<br />"lork described ab ve in accordance wilh the rules and regulations of San Joaquin County and subject to inspeclion and approval.1 !:"----j ,
<br />.._Ci -7 S .2"2-.-201 b
<br />{Signat're Ol'Applicant.Tille Date
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