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,S !d"~APPLICATION FOR ENCROACHMENT PERMIT2Di6jUN !4 I\~\10:53 <br />~.,"l ,~,.-~,",",:l.L1l~~\;J,0 r,',(~,-)Q r..r"l ',.!(••"...,1'\ <br />OFFICE USE ONLY <br />DRIVEWAYS: <br />REF# <br />CR# <br />JOB #73qo6J.-~ <br />APN <br />EXP.DATE <br />VALID <br />STREET <br />AREA <br />TYPE <br />FORMS <br />NOTES <br />(Applicant Name) <br />/AJ{':>1 UU <br />(Mailing Address) <br />Date (,/JCtj!10 <br />To:San Joaquin County <br />Department of Public Works <br />PLEASE PRINT: <br />.u4 qrl-t;l./ <br />(City,Stale,Zip Code) <br />4r:}"-3/(p-171,7(Area Code -Telephone Number) <br />Sketch (Detailed plans may be submitted) <br />Sffe-~tfG()St-.~1l)d <br />i-lt'll>1&"1 \ <br />,/0 f'.s1""subject to pavement cuts shoJI r.ec-eiv~an(1)-inch asphalt concrete overjoy from the centerline (or ~qnetine)to the edeg of the trovel way as per the San JoaquinCountyTrenchClltPotiey.If the pavement is disturbe~on both <br />sides ot the centerline (or adjo'cent lone),then the entireroodway(or affected lanes)sholl be resurfaced.Contractorshallgrindandoverlayw.ithin 10 working days of pern;0!1ent .trench paving,ShoLllder areas shall be brought up to flmsh <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 £6<A-\.,side of /12""<;''''approximately "2 "Ie>~mile ~.Y <br />of f=,"""-.',,>1zx..t.m"",by performing the following work (description of work): <br />!C>J(t~I""e;1.I;lA'j 6a....ClIVI <"YV'c.ll--~L~f~~~tL_~i4~~•..•i<-4'i'oL-/_---------- <br />Work will commence on or about fd?c;;>J /Ii>,I for approximately 110 days. <br />(,/N/IL. <br />~DateSinat <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 />E:\PUIl-SV.WKlMASTER.PS1ENGROACHMEi'IT PERMrr APPUCATION.DOC (01416)