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APPLICATION FOR ENCROACHMENT PERMIT <br />PLEASE PRINT: <br />Date .Lf//LI/J(e <br />To:San Joaquin County <br />Department of Public Works <br />[...-r;J,r .clleMr <br />(Applicant Name) <br />tAJp,,:l--L tV(Mailing Address) <br />~.tmJC-h:<-CfI}qc:;Lo tf <br />(City,State,Zip Code) <br />4o\c 3}("-I 7fL,1 <br />(Area Code -Telephone Number) <br />OFFICE USE ONLY <br />JOB#73JtJ5,J~~REF# <br />APN .CR# <br />EXP,DATE ff/t/h "VALID 4/:41(#T g/I/lh DRIVEWAYS: <br />STREET 1j/,/J/N6',4%.~:t , <br />AREA -:s~tJlI/QUAD C , <br />TYPE ~tLfi .FORMS <br />NOTES <br />~k~,'1Zt?/1dlYA'/7 <br />Sketch (Detailed plans may be submitted) <br />'5f.5'-,z:ptprT't4c-fit£.1:1 Sic.(3'1L.-1-1 <br />--'. <br />'tu,,2.ILSU 'subject to povemeni cuts shall recewe on(1)-inch asphalt concrete overlay from'the centerline (or Laneline:)to the ed'eg of the travel way as per the Son JoaquinCountyTrenchC!Jt ponc(."ff the pavemenI is dis!urbe~on bothsidesofthecenferllneoradjacentlane),then the entrreroadway(or affected lones)sholl be res.urfoced.Co.ntractor.shall g-rind and overlay within 10 working doys of pern;0!lenttrenchpoving.Shoul-der areas sho,ll be brought up to finish <br />grade os direded 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 Ss,M..side of 14-10vU'14.j.(..approximately I J.-'j.d'OOttmile t<) <br />of VXI,',SWL IGf.".,,by perfor ing the following work (description of work): <br />",k <br />Work will commence on or about __4~,(;M~~,~/!~b~for approximately __q~(~)~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 />d1,1/4!/if .Date <br />E:\PU8-SV.WKlMASTER.PSIl:NCROACHME~PERMIT APPLICATION.DOC (01108)