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APPLICATION FOR ENCROACHMENT PERMIT <br />PLEASE PRINT: <br />Date 6LI iN /jft <br />To:San Joaquin County <br />Department of Public Works <br />Pt(ci~,r~;.r ;:;ke-k, <br />(Applicant Name)" <br />4t:'>4t:>wP~J--c ltd(Mailing Address) <br />stz)(./c..+v-Ct/J q')Lo tj <br />(City,State,Zip Code) <br />40lc 3/(r/7~1 <br />(Area Code -Telephone Number) <br />OFFICE USE ONLY <br />JOB#1~Ot>5J-0 REF# <br />APN "CR# <br />EXP.DATE tM4ctp DRIVEWAYS:VALID 1!t5!f.w rCi glIb£.> <br />STREET e"[if :31":•• <br />AREA S1lJc!ql)U QUAD $S • <br />TYPE '"&16 HDle~;!~•FORMS <br />NOTES <br />¥Ui.E,IMc4&/Mtj <br />Sketch (Detailed plans may be submitted) <br />5f-';-te-p!}=JTt.4c.fie 1J 'S~(3'1Z-1-1 <br />~0~~~1 ,subject to pavement cuts sholl receIve on(1)-inch asphalt concrete overlay from'the centerline (or Laneline.)to the edeg of the travel way as per the San Joaquin <br />County Trench C!Jt Paller.'If the pavement.is disturbed on bothsidesofthecenterlineoradjacentlane).then the entireroadway(or affected lanes)shall be resurfaced.Contractor.shan grind and overlay within 10 working dCJ~S of permanenttrenchpaving.Shoulder oreos sholl be broug f up to finish <br />grade CIS direcfed by ,the County. <br />The undersigned hereby applies for ~mission to excavate,construct and/or otherwise encroaGh on CountY Highway Right-of-Way on <br />the'S~side of <5 '"51 aJljlffiximtltely ,'4 ;h},-ec..n;....feet/mile _ <br />of h;',,*\e 'by performing the following work (description of work): <br />:If-,6~'/0,Vi'A7 K7"",,'fi."",,v':P"7 l.."c./:."4p",,'< <br />Work will commence on or about for approximately o days. <br />'dltt/Ie)Date <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 />E.V>US.&V.\VKlMASJER.PS'ENCROACHMEHf PERJ,IT 1I?PLlCATION.DOC (DW8]