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APPLICATION FOR ENCROACHMENT PERMIT <br />PLEASE PRINT: <br />Date OFFICE USE ONLY <br />To:San Joaquin County <br />Department of Public Works <br />(Jtid R,L-n;.),r £ik",Mr <br />(Applicant Name) <br />4 ...>4'6 Wr-.:b c tLJ <br />(Mailing Address) <br />ell!q')Lolf <br />(City,State,Zip Code) <br />JOB#73605J.-0 <br />APN <br />EXP.DATE <br />VALID <br />STREET <br />AREA <br />TYPE <br />FORMS <br />NOTES <br />REF# <br />CR# <br />DRIVEWAYS: <br />4o"r;-3/0 -I 7(.,1 <br />(Area Code -Telephone Number) <br />Sketch (Detailed plans may be submitted) <br />3r:::-a.pfPITf/7-e-1I6l.J 'S/(t3'1Z--I../ <br />- <br />'/~'1.22-7 subje.d to pavement cuts shall recei,,:onCn-inch asphalt concrefe overlay from'the centerlme (or Lane <br />line.)to the edeg of the travel way as per the San JoaquinCounfyTrenchCutPolley.If the pavement is disfurbe~on bothsidesofthecenterline(or adjaoent lane),then the enhre ,roqdway (or affected lorres)shall be resurfaced.Contractor. <br />shall grind and overlay within 10 wa,kinS days of per~0!1enttrenchpoving.Shoulder areas shaH be brought up to frmsh <br />.grade as directed by the County. <br />The undersigned hereby applies for permission to excavate,construct and/or otherwise encroach on County Highway Right-of-Way on <br />the tic,>r side of NIt,!G <,H1'Y;J approximately U feet/mile Swt-L, <br />of flt\0 0 sbvlo1?A,,by performing the following work (descriplion of work): <br />~h L .<:k <br />Work will commence on or about for approximately '10 days. <br />I,the undersigned,certify that I am the owner of the respeclive property,or am qualified to represent the owner and agree to do the <br />work describe e in accordance with Ihe rules and regulations of San Joaquin County and subject to inspection and approval. <br />E:IPUB-8V.WK\Ml\STERPSIENCROACHMENT PERMIT APPlICATlON.DOC (01IOB) <br />I