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ct.!-•..).'~,". <br />Date <br />PLEASE PRINT: <br />{e/J0/!~ <br />APPLICATION FOR ENCROACHMENT PERMIT <br />OFFICE USE ONLY <br />DRIVEWAYS: <br />REF# <br />CR# <br />JOB #15005J.~ <br />APN <br />EXP.DATE <br />VALID <br />STREET <br />AREA <br />TYPE <br />FORMS <br />NOTES <br />,-C <br />(Applicant Name) <br />San Joaquin County <br />Department of Public Works <br />-PC; <br />To; <br />&h,s!(,10 <br />(Mailing Address) <br />_'7:>kk-+ev..Ott 1S2o'-! <br />(City,State,Zip Code) <br />l.fr:1:s-31 (.,-1 7C.7 <br />(Area Code -Telephone Number) <br />Sketch (Detailed plans may be submitted)<;,t:'r:;1-4-Tfl4c..H IE j'~St:e 7C-If <br />i.-i l.-V;,:z-(I ( <br />J~elv~Jw-e subject'to pavement cuts shall receiv:anCO-inch asphalt ooncrete overlay from the c.enterlme (or .Lane <br />fine)to the edeg of the travel way as per the San JoaquinCountyTrenchC!Jt Pofiey.If the pavement is disturbe~on bethsldesofthecenterline(or adjacent lane),then the entireroadway(Qr affected lanes)shall be,r~surfaced.Contrado,.shall grind and overlay within 10 workmg.dol'S of per~d!Jenttrenchpaving"Shoutder areas shall be brought up to finishLL_11.grade as directed by the County_ <br />The undersigned hereby appllesJor permission to excavate,construct and/or otherwise encroach on Cpunty Highway Right-9f;Way on <br />the S..side of \7 e\IId.<-~approximately I(,.?s feet/mile 1::"'0t- <br />of UA t.o)\l...J ,S"ht 4",,by performing the following work (description of work):'"I"'/)l"'fI">:v'.<ill;""r::.""/Snfrj6"q Lt's k "N-fb;c .. <br />Work will commence on or about for approximately /2D days. <br />{plt'?!//,•Date <br />l~;+C([Y)'.""(...v <br />ant -Title <br />i,the undersigned,certif that I am the owner of the respective property,or am qualified to represent the owner and agree to do the <br />work described .accordance with the rules and regulations of San Joaquin County and subject to inspection and approval. <br />E:\PlJa-SV.WKlMASTERPSlENCROAGHMENT PERMIT APPLICATION.DOG (OlJOB)