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PLEASE PRINT: <br />APPLICATION FOR ENCROACHMENT PERMIT <br />...'.,.'',',i ~I'*_ <br />.i J /'.:,..1l.J!i-";:'.U U N r y <br />2016 jur~I 4 tii')10:53 <br />Date (,11'1II to,I . <br />To:San Joaquin County <br />Department of Public Works <br />(Applicant Name) <br />uk:."!UU <br />(Mailing Address) <br />OFFICE USE ONLY <br />JOB#7300:;;L~0 <br />APN <br />EXP.DATE ----~~~-~~---VALID <br />STREET <br />AREA <br />TYPE <br />FORMS <br />NOTES <br />DRIVEWAYS: <br />.u4 CJS4t{ <br />(City,Stale,Zip Code) <br />4bY -3/(0-17 (,7 <br />(Area Code -Telephone Number) <br />Sketch (Detailed plans may be submitted). <br />Sff~I-4-=m4tHG()S~f--1lJd <br />/..f1."'"V.•'i'J , <br />lOt""~1"subject to pavement cuts shall recetv:on(1r-inch asphalt concrete overlay from the eenterhne (or ~dneline)to the edeg of the trovel 'Nay as pe,r i_he~an JO'ClqWrlCountyTrenchC!Jt porky.If the pavement IS djsturbe~on bothsideSofthecenterline(or adjacent lane),then the entire troadway(or affected lanes)shoji be r~surfaced.ControC Oftshallgrindandoverlaywithin10workingdaysofpern;0!lentrenchpaving.Shaul-der areas shall be brought up to fn').lsh <br />grade os diredcd 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'-S;()~side of ID"'"9 approximately :50>.~mile t<# <br />of T 5uKL.nW ,by performing the following work (description of work):L tL <br />Work wiil commence on or about for approximateiy \10 days, <br />I,the undersigned,certify that 1am 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 />(,/N/lL.. <br />Date <br />E:\PUll.sV.WIi\MASlER-PS\ENCROACHMENT PERMIT APPUCATlON.OOC ((11mB)