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APPLICATION FOR ENCROACHMENT PERMIT <br />PLEASE PRINT: <br />Date '-/ILI..j IIf.er,I <br />OFFICE USE ONLY <br />To:San Joaquin County <br />Department of Public Works <br />{Jfie!R,{'"'4~r .c«e-Mf <br />(Applicant Name) <br />461.fr::,wP),b L ttJ <br />(Mailing Address) <br />Shllje-iv-CIIJ q+;2-0 tf <br />(City,State,Zip Code) <br />1-161,(-3/&-I 7&1 <br />(Area Code -Telephone Number) <br />JOB#13iJP5;-& <br />APN <br />EXP,DATE <br />VALID <br />STREET <br />AREA <br />TYPE <br />FORMS <br />NOTES <br />REF# <br />CR# <br />DRIVEWAYS: <br />Sketch (Detailed plans may be submitted) <br />:5tJ-.fi-m--r(/Je.-flt£'[)SI':r'lZ--ld <br />. <br />~r1 ttr77 subje.d to pavement _cuts shoJI receive on-(1)~inch asphalt concrete overlay from'the centerline (or LoneIi,ne)to the edeg of the travel way as per the San Joaquin <br />County Trench G[.lt POlIct jf the pavement is disturbe~on bothsidesofthecenterlineoradjacentlane),then the entIreroqdway(or affected lan-es)shall he 'resurfaced.Co,ntrador. <br />shaf)g'rind and overJay within 10 workin9 days of per~o!"enttrenchpaving.Shoulder areas shall be brought up to flnli~hgradeasdirectedbytheCounty. <br />The undersigned hereby applies for permission to excavate,construct and/or otherwise encroach on Counfy Highway Right-of-Way on <br />the 5ov¥:>.side of 1hb.v1 4u approximately :;-/(,.<f.6BlImile&Y <br />of .(S-+t>.L-/:::./"""by performing the following work (description of work): <br />'~Ui <br />Work will commence on or about for approximately days, <br />I,the undersigned,certify that I am the owner ofthe 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 />4/I'1/1f,-,Date <br />E:\Pua~V.WK\MI\STER.PSlENCROACHMENT PERMlT APPLICATlON.DOC (D1JGB)