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.' <br />APPLICATION FOR ENCROACHMENT PERMit <br />OFFICE USE ONLY <br />., <br />"..',..'.." <br />j'')i~(,:,d1:-; <br />Date (,It 'f /I (prJ. <br />PLEASE PRINT: <br />To:San Joaquin County <br />Department of Public Works <br />DRIVEWAYS: <br />REF# <br />CR# <br />JOB #13d:J'S'J.-<'::> <br />APN <br />EXP.DATE <br />VALID <br />STREET <br />AREA <br />TYPE <br />FORMS <br />NOTES.u4 CIrz_IJI./ <br />(City,Sta~e,Zip Code) <br />(Applicant Name) <br />uk::,"r UU <br />(Mailing Address) <br />4bY -3/1,.-17 C,7(Area Code -Telephone Number) <br />Sketch (Detailed plans may be submitted) <br />Sff(;~IfIH>S~~llH <br />LH(,.c &tJ,ll' <br />~Iv!hw..subject 'to pavement cuts shall rscelv,:an.(1)-inch asphalt conc,ete overlay from the eenterhns (or ~anefine)to the sdeg of the travel way as per t.he ~an JoaqUinCountyTrenchC\J+PoliCY.If the pavement IS dlSturbe~on bothsidesofthecenterline(or adjacent lone),then the entrre troadwny(or affected lanes).shall be r?surfaced.Contrac ort .shan grind und overlay witl:l\n 10 workln-g d0'hS of per~a~~ntrenchpaving.Shoulder areas shall be broug t up to flli.lS <br />grade as 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 CA'>I-side of /i-..V11 i <,~approximately 4 &tlmile Nov.\-'- <br />of STh<I<.fWIJ ,by performing the following work (description of work):IL <br />Work will commence on or about for approximately 110 days. <br />I,the undersigned,certify that Iam the owner of the respective property,or am qualified to represent the owner and agree to do the <br />work described abo .accordance with the rules and regulations of San Joaquin County and subject to inspection and approval. <br />(,/flI/lL. <br />I Date <br />E:\l'lJB-SV.VlKlMASTER.PSIENCROACHMENT PERMIT APPlICATION.DOC (01/08)