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, <br />APPLICATION FOR ENCROACHiVlENT PERMIT <br />PLEASE PRINT: <br />Date <br />To:San Joaquin County <br />Department of Public Works <br />P(fcl R(t.,-z;~r ;:;-ke£;( <br />(Applicant Name) <br />4641::>Wf~J.-f-tV(Mailing Address) <br />Stnrlc.--tv--C{f}Q')2-0 tf <br />.(City,State,Zip Code) <br />4ok-3/("-/7fL,1 <br />(Area Code -Telephone Number) <br />OFFICE USE ONLY <br />JOB #13aY:id--<.0 <br />APN <br />EXP.DATE ~~~~-I-'-<=~~-+-~~_ <br />VALID <br />STREET <br />AREA <br />TYPE <br />FORMS <br />NOTES <br />DRIVEWAYS: <br />Sketch (Detailed plans may be submitted) <br />5t5'-tf.tiJ:='lTt4c.fie 1)S~~'/L.-I.J <br />- <br />4].r4y ~sS'"(subje.cf to pavement cuts shall receive on <br />(1)-inch asphalt concrete overlay from -the centerline (or ~aneli,ne.)to the edeg of the travel way as per t~e ~qn JoaquinCounfyTrenchC!Jt Policy.If the.pavement IS dlsfl.Jrbe~on both <br />sides of the cenferline (or adjacent lone),then the entire .roqdway (or affected lanes)sholl be resurfaced.Contractor.shall grind and overlay within 10 working days of per~0!1enttrenchpaving.Shoul-der areas shall be brought up to flntsh <br />grade as directed by the County. <br />The undersigned hereby applies for ~mission to excavate,construct and/or otherwise encroach on Counfy Highway Right-of-WaJ!;0n <br />the Cq .s:t Side of LJ,L,L&'o C--,.--_approxlmateiy 1.-'i ,&i.6t/mlle __~__o f ,'<,f ,Lor-crb'vtd ,by performil)!J the f~lIowing work (description of work): <br />C>,0/'11,vf IA--c w-c \("I'C-e "v <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 ruies and regulations of San Joaquin County and subject to inspection and approval. <br />t.W<t,/lf". <br />Date <br />E:IPUB.SV.WKlMAST£R.PStENCROACHMENT PERMIT APPlICATION.OOG (G1/()B)I