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APPLICATION FOR ENCROACHMENT PERMIT '>n'f rlll_Ol'"i V v _,U <br />PLEASE PRINT: <br />(Applicant Name) <br />OFFICE USE ONLY <br />JOB#13()o5J-G>REF# <br />APN ..CR#. <br />EXP.DATE /O/If-tt> <br />VALID '7f!/ltt>'T 10/1/;£0 DRIVEWAYS: <br />STREET k't;J4/}?1Th'itT>-•, <br />AREA $r?~r-I QUAD ce:.-• <br />TYPE $'01%.-r#6,JeH,.x:,• <br />FORMS ~..;,e.;;'?,tUn'"C•..-I,fJ1te-; <br />NOTES <br />,. <br />LtD'!\;WP~+/.-P() <br />(Mailing Address) <br />Stoc k.W.:....(.18 Q5"2..c,t.( <br />(City,State,Zip Code) <br />To:San Joaquin County <br />Department of Public Works <br />Yt>\-?olio -{7f"J <br />(Area Code -Telephone Number) <br />Date <br />Sketch (Detailed plans may be submitted)-S 12.1..7 ("lt~ <br />::>I:r;14-1'Tl4-<-(-1,3\\-s.K.f:1c.-I-1 <br />~l'1~<>..u.""subject to pavement cuts sholl rece'iv~an(1)-inch asphalt concrete overlay from the centerlme (or ~ane <br />fine)to the edeg of the travel way as per i.he ~dn Joaquin b thCountyTrenchCutPolicy.If the pavement IS dlsturbe~on 0sidesofthecenterline(or adjacent lane),then the entire troadway(or affected lanes)sho'll be resurfaced.ContraC.orshallgrindandoverlaywithin10workingdaysofpern;a~enttrenchpaving.Shoulder areas shall be brought up to f1l11Sh <br />grade as directed by the county. <br />The undersigned hereby apPI~1:permission to excavate,construct and/or otherwise encroach on County Highway Right-of-Way on <br />the ~;d side of VI""'1"u"",hl\approximately \1 .;;.(!jleVmile ~ <br />of (;"''-11<-I ,3!«IS..~,by performing the foilowing work (description of work): <br />\:.)""fJ"-;;\z\\,J:::,HS WFl(I!l"I.Jb\\E S '("Ii"l'YV' <br />Work wiil commence on or about_J~-~I_-~/~lo~for approximately __q~t:>~days. <br />I,the undersigned,certifyJhat-raiii1he owner of the respective property,or am qualified to represent the owner and agree to do the <br />work described abov 'inacc:;spance with the rules and reguiations of San Joaquin County and subject to inspection and approval. <br />/(v"",.G,w,jl~L <br />19nature of Applicant -Title <br />E:\PlJS-SV_WK\MI\ST"EI1.PSIENCROACHMENT PERMITAPPUCATlON.OOC (01/OS)