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Field Paving FormmPacificGfiSam/ <br />t f.,Electric CrJlli/Jimy <br />\.,---------- <br />M~:ff\1'Z.16 <br />Foreman Name:~e,~'---- <br />PM Number:1.1'~~/_ <br />Permit Number:_ <br />.Perroil Expirallon D~le:_._ <br />Stre.et Address:t q {Py 11.(O'fl1.Sr <br />Cross Sln,et:~"=~~<e;_.:T'~~-~-~~~-e:::~-- <br />CIty/County:T/R'CV]1a..)I SJ ~ <br />If <br />In Concrele:.Y IN <br />Re.flO(:live:Y IN <br />Correrele J AsphalL <br />1--__1ea <br />1--_-1eafrea 13"x 24'117'X 30'124'x 3S"ea 15'123'I---f <br />L ....._...Ja.a 30'x30'13~'x?2'Hs'x 4~' <br />Note;; <br />Pia.C8 Paver /slone /Brtck ~ <br />Traffic Marker Dois .ea <br />PJug1%'t>as ProspeclHole ...:ea <br />OIlier <br />.Color:Y /N I Aggregale:YIN I.Decoralive/Slamped:YIN. <br />Cqlor:Y /N 1 Aggregale:Y/N I oe90rallve(S.lamped:Y IN <br />Coior:Y /N 1 Aggreg~le:V./N 1 DetdralixejSlaiDped:Y /N <br />Color:YIN IAggregate:yIN 1 Deccralive/Siamped:Y IN <br />AdJusUR.eplace <br />Manhole Franle <br />Sidel'laik.Gas Valve Box <br />.S.econdary ,Electrical BoX <br />VaNe Frame <br />Valve.Cover <br />inches <br />_._inchgs <br />4"18"itCrosswefk <br />Dept!> <br />~iJ1Ch~S <br />_.iijches <br />Deptll <br />_.lnches <br />inches <br />._.......In:ches <br />inches <br />inches <br />Domes:Y iN <br />Gulter:Y/N <br />Width <br />II <br />If <br />~a SiZe:~41 #5 <br />W.xL Deptf, <br />'iSinches <br />inc~es <br />_._".over_' <br />Inches <br />I <br />I <br />I <br />I <br />ASjlha!l <br />Fill <br />Asphalt/Conl'1ele Coni.bo <br />Grind <br />Asphalt Fabric <br />Asphalt Berm i Curb <br />.S'!1iI C\lt <br />Se.a.! <br />.slurry /Fog /Sand <br />Striping <br />Fain! <br />Thermoplasllc <br />Traffic Le~enil <br />Qouble Center L~ne <br />~WS90ich~an'" <br />.Con,or~~e <br />.Rozdl'lay <br />SWl'lalk <br />Sld~Walk <br />Qrive\'iay <br />.Orivel'l.y <br />Curb'Ramp <br />Curb <br />V"IJeyGuller <br />09ViSI~ <br />I . <br />~t>~..:0