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,,' <br />APPLICATION FOR ENCROACHMENt PERMit 2010JUN 14 M'!\0'53 <br />PLEASE PRINT:~"'I -'r ',,".'•••••:i"',':--',"",'v"R \<.SDtr-I ',.J:-•~ <br />Date (,!I'i U (pif' <br />OFFICE USE ONLY <br />DRIVEWAYS: <br />REF# <br />CR# <br />JOB#7~~~~-~ <br />APN " <br />EXP.DATE <br />VALID <br />STREET <br />AREA <br />TYPE <br />FORMS <br />NOTES <br />"GJA q~~t/ <br />(City,Stale,Zip Code) <br />(Applicant Name) <br />UJ{:>t UU <br />(Mailing Address)4rNo <br />To:San Joaquin Ceunty <br />Department of Public Works <br />4r:,y "JIlfrl7 (,7 <br />(Area Code"Telephone Number) <br />Sketch (Detailed plans may be submitted) <br />sffe /lPiTI4t.ff!3f>S\:.~1l-fd <br />l-j t.U <:IU,S- <br />ID ~S'--'SUbje.d t~pavement cuts shall receiv:an <br />(1)-lnch asphalt concrete overlay from the centerline (or .Laneline)to the edeg of the trovel way as per t~e ~(m JoaqwnCountyTrenchCutPoney.If the pavement J~dtsturbe~on both <br />sides at the cenferline (or adjacent lane),the,n the entfre troadway'(or Clffeeted lanes)shoJI be resurfaced.ContrClc-orshallgrindandoverlaywithin10workingcloysof~-er~a.nhnt.trench paving.Shoulder areas shall be brought up a lOIS <br />grade as direded 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'side of /0-11-:;'1 approximately 7.('\~mile t<b <br />of 'ST ,Sll>UcTVllJ ,by performing the following work (description of work):L k. <br />Work will commence on or about (Pbol~,.,for approximately 110 days. <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 described abo accordance with the rules and regulations of San Joaquin County and subject to inspection and approval.. <br />~/I'{//L"Date <br />E:lPlIB-SV.\'IKIMASTERPS\ENCROACHMEm"PERMrr APPLICATION.DOC (DlI08)