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APPLICATION FOR ENCROACHMENT PERMIT <br />PLEASE PRINT: <br />Date il/IIf/I&,I OFFICE USE ONLY <br />To:San Joaquin County <br />Department 01Public Works <br />Pad {;,(~J,r .ckekf <br />(Applicant Name) <br />4..,41:::.c/UP'>.l--I-It,) <br />(Mailing Address) <br />~h)(lc--Iv-CJIJ 1<;2-0 q <br />(City,State,Zip Code) <br />46Sc3lw-17~1 <br />(Area Code -Telephone Number) <br />JOB#1Qoo'5a.-v REF# <br />APN CR# <br />EXP.DATE ~-!l-o-- <br />VALID ~'TO ~~I(P~.__ <br />STREET -D:Ju)l'iS Rd. <br />AREA Sror..-ic:.:n,,J QUAD _W _ <br />TYPEl>,,-.lt lA.k",(';'r •• <br />FORMS 'SS(ww «.-?j •NOTES I , <br />DRIVEWAYS: <br />Sketch (Detailed plans may be submitted) <br />5(5-tf-~f/l{...lIt£'()'S~t3'1Z-I..J <br />-"?!J'1 Z-'12-"¥subject to pavement cuts shall receive an <br />(1)~inch asphalt c-oncrefe overlay from -the centerline (or ~dneIi,ne)to the edeg of the troyel way as per the!Son Joaquin <br />County Trench C!Jt Poljot If the pavement is disturbe~on bothsidesofthecenterlineoradjacentlane),then the entrreroqdway(or affected lanes)shaU be resurfaced.Co,nirador-,shal!g'rind and overlay within 10 workins days of per~a~ent <br />. <br />trench paving.Shoul,der areas shall be brought up to finish <br />grade as directed by the county., <br />The undersigned hereby applies lor permission to excavate,construct and/or otherwise encroach on County Highway Right-ol-Way on <br />the tU<>':'l=b side 01 b6;\71c~rU approximateiy 447 ..leeUmile i<A"",( <br />01.~,Soh u,,,,,by perform in the lollowing work (description 01work):k','''' <br />Work will commence on or about lor approximately days. <br />I,the undersigned,certily that I am the owner olthe respective properly,or am qualified to represent the owner and agree to do the <br />work describe e in accordance with the rules and regulations 01San Joaquin County and subject to inspection and approval. <br />E:IPUB-SV.WKWASTERl'SIENGROACHMENT PERMIT APPUCATION.DOC (OtIOB) <br />••_f>