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APPLICATION FOR ENCROACHMENT PERMIT <br />PLEASE PRINT: <br />Date 1j/1'-I/ILt <br />To:San Joaquin County <br />Department of Public Works <br />Ptfcl R,{'TI:;;,r '&/(c-Mr(Applicant Name) <br />4 r:Nt>tAJp :..,j..-C AJ <br />(Mailing Address) <br />'Qtz}r1cA",-elf)q<)Lo q <br />(City,State,Zip Code) <br />4t,Sc 31 ro-I 7{~'1 <br />(Area Code -Telephone Number) <br />OFFICE USE ONLY <br />JOB#'l3005J.-(O REF# <br />APN 4.CR#EXP.DATE <br />VALID r~DRIVEWAYS: <br />STREET <br />~r,hIoT6 eM;';•l}l-rH SI ' <br />AREA ~/IJ QUAD l3>, <br />TYPE =//PM . <br />FORMS <br />NOTES <br />~£.,)~'M;fCJ,COf1M~ <br />. <br />Sketch (Detailed plans may be submitted) <br />;Sr.:u:pf)=rrp4C-IIt£b 'S~(3'/Z-I-J <br />--;I~3-,5G:.i subject to pavement cuts sholl receiv~on <br />('1)-inch asphalt concrete overlay from -the centerline (or Laneli,ne)to the ed-eg of the travel way as per the San Joaquin <br />County Trench C!Jt POJiC0.If the pavement IS dishJrbe~,on bothsidesofthecenterlineoradjacentlane),then the entIreroqdway(or affecled lon-es)shall be resurfaced.Co,nirador.shall g-rind and overlay within 10 working days of pern"!o.nenttrenchpaving.Shoulder areas shall be brought up to frnlsh <br />grade os directed by the County. <br />The undersigned hereby appiies for perm~ion to excavate,construct and/or otherwise encroach on County Highway Right-of-Way on <br />the Nr;v46 side of e ("S,T approximately Z-c,u.~ite a,,/= <br />of '.,~,by rforming the following work (description of work): <br />--e viC-Z <br />Work will commence on or about 47~/7r;;,for approximately 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 describe e in accordance with the rules and regulations of San Joaquin County and subject to-inspection and approval. <br />E:\f'UB-5V.WKlMASTER,PSlENCROACHMENT PERMIT APPUCATION.DOC (ai/DB)