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., <br />,..t•.,_I •,~.~.',S/\:'1 ):~i/'~O:jl,'~'~'('.(jUblTY <br />APPLICATION FOR ENCROACHMENT PERMIT1D1n-lUi\!It;i:;h 10:52 <br />PLEASE PRINT: <br />Date ~/I'lj!fo <br />To:San Joaquin County <br />Department of Public Works <br />4r:No <br />(Applicant Name) <br />LJl'st UU(Mailing Address) <br />.fAA 1S44 <br />(City,Stale,Zip Code) <br />OFFICE USE ONLY <br />JOB#1Jio5J.''''REF# <br />APN ,CR# <br />EXP.DATE I#w. <br />VALID blu/i""~io ;Iii/!""DRIVEWAYS: <br />STREET 'iJjpu-he I • <br />AREA j~o~QUAD G~• <br />TYPE <br />FORMS ;;Its'!,w:Z'd';$~ <br />NOTES <br />40Y -3/1",-171,7(Area Code -Telephone Number) <br />Sketch (Detailed plans may be submitted) <br />Sffc VA714t-IfG(,)S\:.~1l-f1 <br />3.lIl 41.-/l./It> <br />.WJ~subject to pavement cuts shall receiv~an(1)-inch asphalt concrete overlay fTom the centerlme (or .Laneline)to the edeg 01 the travel way as per the San JoaqwnCountyTrenchCutponc~.If the pavement is disturbe~on bothsidesofthecerlterlineoradjc'cent lone),then the entfreroadway(or affected lanes)shoJI be _resurfaced.CO-ntroctorshallg-rind and overlay within 10 working d,ays of per~a!l~nttrenchpaving.Shoulder areas shaJl be brought up to mls <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 1':'4>'"side of tJ",~VI".,.approximately "I';.r dellt/mile :&.o.AS <br />of .•.,r J STu,1c:..17JI1-I,by performing the following work (description of work): <br />v L lL <br />Work will commence on or about 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 />(.,.IFIllL-.Date <br />E:IPUB-SV.WKlMASTERPSlENGROACHMEflT PERMIT APPUCATION.DOC (01108)