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APPLICATION FOR ENCROACHMENT PERMIT <br />PLEASE PRINT: <br />Date 4!14//0,;} <br />To:San Joaquin County <br />Department of Public Works <br />{Jt[c!~,{;z;~r &i(e-Mr <br />(Applicant Name) <br />41:>41::>Wp~J--c tU(Mailing Address) <br />-=iliv)c-/-rA-.-til!q<;Lo tf <br />(City,State,Zip Code) <br />4o'c 3/ro -I 7{o 1 <br />(Area Code -Telephone Number) <br />OFFICE USE ONLY <br />JOB#'1g[K)6)-~REF# <br />APN CR# <br />EXP.DATE .81fh <br />VALID #iltl"j 0 8jtItGo DRIVEWAYS: <br />STREET L4~/e/$,• <br />AREA Sf~/l QUAD $5 , <br />TYPE ~R.k .FORMS <br />NOTES <br />~tV~'£-#1,?itYlc4 &lI?d0 <br />Sketch (Detailed plans may be submitted) <br />Se-e m-rt4c fit£.1)Sr.{3'/L.-I..} <br />- <br />Lt1J-ll{~(,~bjed to pavement cuts sholl recei'l:an <br />en-inch asphalt concrete overlay from.the centerlme (or Lonel\ne)to the edeg of the trove!way as per t~€!~an JoaquinCountyTrenchC[Jf Policy.If the pavement ts dlsturbe~on bothsidesofthecenferline(O'f adjaceni lane),.then the enhreroqdway(or affected lanes)shall be r-esurfoced.ContradorshaHg'rind and overlay within 1a workin~days of pern;a.nenftrenchpaving.Shoulder areas shall be brought up to frmshgradeosdirectedbytheCounty.. <br />The undersigned hereby applies for permission to excavate,construct and/or otherwise encroach on County Highway Right-of-Way on <br />the !L +side of ~.L "iOV.(I <,"approximately /5cl te:eJimileS:rr(e, <br />of v.w,SfulAm,.,by performing the following work (description of work): <br />~.l'0 u'c fJh/V <br />Work wiii commence on or about for approximately _9~6~days. <br />I,the undersigned,certify that i am the owner of the respective property,or am quaiified 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 />'-(Itt/a.Date <br />E:IPUB-5V.WKlMASTERPSlENGROAGHMENT PERMIT APPUGATION.DOG (01/(lB)