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APPLICATION FOR ENCROACHMENT PERMIT <br />DRIVEWAYS: <br />REF# <br />CR# <br />OFFICE USE ONLY <br />JOB #1$»5)-v <br />APN <br />EXP.DATE <br />VALID <br />STREET <br />AREA <br />TYPE <br />FORMS <br />NOTES.(AI)QS4t.( <br />(City,Sta~e,Zip Code) <br />(Applicant Name) <br />lUe.'T UU <br />(Mailing Address) <br />To:San Joaquin County <br />Department of Public Works <br />Date (,Ltv /I (p,I . <br />PLEASE PRINT: <br />40Y -3/",,-/7 (,7 <br />(Area Code -Telephone Number) <br />Sketch (Detailed plans may be submitted) <br />Sffc WfT1.4t.tfG(,)S'r-f-.TlH <br />£-11 v C>Ip/bi( <br />V\V\Js.ov subjed to pavement cuts sha.ll rec-eiv:on <br />(1)-inch asphalt concrete overlay from the centerlme (or ~one <br />line)to the edeg of the trovel way as per the Son JoaqwnCountyTrenchCutPolicy,!f the pavement is dlsturbe~on both <br />.sides of the centerline (or adjaoent Jane),then the entrreroadway(or affected lanes)shotl be r?surfoced.Contractor <br />shan grind dnd overlay within 10 workrng days of pern;°!"lhttrenchpaving.Shoulder areas sholl be brought up to hnls <br />grade os dlreded by the County. <br />The unAersigned hereby applies for permission to excavate,construct and/or otherwise encroach on County Highway Right-of-Way on <br />the f:4 ~r side of W 0/1.J<Srf--approximately /&0 ~mile 5"..k<- <br />of FVLVlnO\A.r $-S77!U::.:(liIJ,by performing thefoliowing work (description of work): <br />v L lL <br />Work will commence on or about &bo I Iii>,,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 />(,/JlI//&. <br />Date <br />E:IPUIJ.SV.WK\Mi\STERPSIENCROACHMENT PERMITAPPLICATION.OOC (OlK18)