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Dale: <br />Foreman Name: <br />PM Numbel': <br />Field Paving FormmPilcificGilSand,'t"Efl)cfric C;l/lJjlilllVq--",_.._.._---_.-g.J-t5' <br />J'eI/tN Pt!f"E"a :21\1445 I <br />Street Address: <br />'Cross Street: <br />City/County: <br />Permit Number:~~~_ <br />Permit E'plr,atlon Date:~_ <br />915"s.lVHt,.,m /Iv/!': <br />,G~/11-1-1'"ST' <br />5r«-J'l.ra,.,. <br />r::&J,IICd'lWiiL' <br />Color:Y/N r Agw~ate:YIN I DewralivelSlamped:Y/N <br />Ctll"r:Y/N I Aggriiga(e:Y/N Ioecqrallve/Slainped:Y/N <br />CQlor:'1/N I A9gregaJ~:Y /N I Detora!i~elSta!l1ped:Y /N <br />Color:Y/N I Aggr~ate:Y/N I Decorative/Stamped:Y/N' <br />'Other W XL <br />Pla,ce Paver /Stone I Brick ~ <br />TrafficMarker Dois,ea <br />'PILig1Y.'Gas Prospeel Hole ",'."ea <br />inConer~ie:Y/N <br />Re.neclive:y /N <br />Conctele JMphall , <br />f-"--_-leaea <br />t----tea 13'x24'I17'x30'124'x36" <br />t----tea 15"123' <br />~::::::::::::~ea30'it 30'132'x ~2'i48',,ji\' <br />AdjustlReplace <br />Ma,nhol,eFrame <br />Sidewalk Gas Valve80' <br />'Seoondary EleCtrical80' <br />Valve Frame <br />ValveCover <br />Depth <br />_inches <br />_'inches <br />_irr'phsq <br />_inches <br />inches <br />Domes:Y /N <br />Guller:Y/N <br />_,_"over_' <br />_,_in,ehes <br />D,eptll <br />k-inche:s <br />_'_'inches <br />a Siz~:#41 #5 <br />Depth <br />~inehes <br />inches <br />WxL <br />WkL <br />If <br />If <br />e <br />,5" <br />I <br />Con,crele <br />ROaOway <br />Sidewalk <br />Sid(lWalk <br />DriveWay <br />,Driveway <br />turbR~mp <br />Curb <br />V;>lIey(lutier <br />09\'iel~ <br />~,Sh,al\ <br />~Mill &Fill <br />Aspha!!/Concrete Combo <br />Griod <br />A$ph'1ltF~blic <br />Asphalt 8erm ICurb <br />SaW C\lt <br />,Note~WIdth <br />inches <br />_,_inches <br />ea <br />f <br />i ,4'WI 1i'Crosswaik <br />I <br />I <br />I <br />I <br />Slurry /Fog /Sand <br />Stripin$l <br />Paini <br />ThermoplasUe <br />Trafficl~gend <br />Dovble Cenl~rlane <br />3M"ScoIChlane' <br />\.r <br />1-' <br />~.. <br />, <br />I...\.