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APPLICATION FOR ENCROACHMENT PERMIT <br />PLEASE PRINT: <br />Date 4ktl/~,,OFFICE USE ONLY <br />To:San Joaquin County <br />Department of Public Works <br />Plie!R',('on;.),r .r:;-kc.M <br />(Applicant Name) <br />464t>tAJp,,1=CAd <br />(Mailing Address) <br />'bh\llc..t.<-elf!1<)2-0 tf <br />(City,State,Zip Code) <br />4oY-3l to -I 7(s,1 <br />(Area Code -Telephone Number) <br />Sketch (Detailed plans may be submitted) <br />5~m-r{t4e-IIt£1J Sr:.t3'1Z-I-J <br />JOB #7 3rJd5J ~~ <br />APN <br />EXP,DATE <br />VALID <br />STREET <br />AREA <br />TYPE <br />FORMS <br />NOTES <br />REF# <br />CR# <br />DRIVEWAYS: <br />. <br />d~'1"15~\..""1.':subJe.e-tto pavement cuts sholl rec-elve on(1)-inch asphalt concrete overlay from'the centerHne (or Lone <br />line.)to f.he edeg of the travel way as per the Son Joaquin <br />County Trench C!Jt Policy.\f the pavement rs djsturbe~on bothsidesofthecenterline(or adjacent lone),then the entIreroqdway(or affected lon-es)shall be resurfaced.Contractor-.shall grind and overlay within 10 working d.ays of per~a!"lent <br />trench paving.Shaul,der areas shall be brought up to finish <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 S6~side of »y I4w .approximateiy [J teetlmile ffi >.J <br />of D '\',a-AuvPb«,by perf rming the following work (description of work): <br />Work will commence on or about 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 S~n Joaquin County and subject to inspection and approval. <br />E:IPU&SV.WK\MASTERPS\ENCROACHM~rrr PERMIT APFtlCATlON.OOC (01108)