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APPLICATION FOR ENCROACHMENT PERMIT <br />PLEASE PRINT: <br />OFFICE USE ONLY <br />JOB#73t»5J..-ca REF# <br />APN CR# <br />EXP,DATE e/t~{p <br />VALID #{j40 ~li~DRIVEWAYS: <br />STREET It s-r:• <br />AREA ~.kf"'1 QUAD 9S • <br />TYPE ~!e '.FORMS <br />NOTES <br />9$~~/A-~17MCibl'76/Kj <br />Date i..(//4 /1~,'I <br />To:San Joaquin County <br />Department of Public Works <br />{Jlie!R,L.,-r;J,r rke-£;r <br />(Applicant Name) <br />4c,l-{D wP ;-,:l--c tLJ(Mailing Address) <br />~t7lrJc-k til!q')Lo tj <br />(City,State,Zip Code) <br />tl6\c 3/(iJ -/7&1 <br />(Area Code -Telephone Number) <br />Sketch (Detailed plans may be submitted) <br />:se:-tf.1FrT1/l-C-1I1f£1'.1 'S~r'1Z-IJ <br />- <br />sblbjed to pavement cuts shall receive an <br />(1)-inch asphalt concrete overlay from-the centerline (or Loneli.ne)to the edeg of the travel way as per the San JoaquinCountyTrenchCl.lf Policy,If the pavement is disturbe~on bothsidesofthecenterline(or adjacent lane),then the entire <br />roadway (or affected lon-as)shall be resurfaced.Contractor-. <br />shan grind and overlay within 10 working days of pem;0;tent <br />trench paving.Shaul,der areas shall be brought up to finish <br />grade QS 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 5.l side of e /21\5/approximately b'i 7 &t!mile u)e'r{ <br />GfST S:::{;ot)C-tr-"-',by performin the following work (description of work):~,C ~'"<:'"-fl',1(' <br />Work will commence on or about 0/»11(,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 San Joaquin County and subject to inspection and approval. <br />6'i/1{f1/ft,.Date <br />E:\PUB.sV.WKlMASTER.PSlENCROACHMENT PERMITAPPLICATION,DOC [01l0S)