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••Pacific Gas and <br />~&~Electric Company <br />Date:J,-15'...~b <br />Foreman Name:ll.uJ tJt¥-1it/~ <br />PM Number:''l.iZiu Z~"3Z~ <br />Concrete W x L Depth <br />Field Paving Form <br />Street Address: <br />Cross Street:.CityED- <br />PenmitNumber:_ <br />Permit Expiration Date:_ <br />;061 &/;IlC~[WI <br />(II)AC I tJ t 41.e-•S/ac:km)1 <br />Color:Y /N 1Aggregate:YIN I Decorative/Stamped:Y /N <br />Color:Y /N I Aggregate:Y /N I Decorative/Stamped:Y /N <br />Color:Y /N I Aggregate:Y /N 1 Decorative/Stamped:Y /N <br />Color:Y /N 1Aggregate:YIN I Decorative/Stamped:Y /N <br />inches <br />inches <br />inches <br />Inches <br />Inches <br />Domes:Y /N <br />f Gutler:YIN <br />f <br />ea Size:#4 1 #5 <br />I <br />I <br />Roadway <br />Sidewalk <br />Sidewalk <br />Driveway <br />Driveway <br />Curb Ramp <br />Curb <br />Valley Gutler <br />Dowels <br />WxL Depth <br />/.;;//inches <br />inches <br />_~over <br />Inches <br />ff <br />DepthB~inches <br />inches <br />WxL <br />[IJ <br />Width <br />In Concrete:Y /N <br />Reflective:YIN <br />Concrete IAsphalt <br />1--_---1eaeaf---J ea 13'x 24"117"x 30'124"x 36"1----1ea 15'I 23"1----1ea 30'dO'132"x 32'148'x 48"'---_----.J <br />Notes <br />AdjustlReplace <br />Manhole Frame <br />Sidewalk Gas Valve Box <br />Secondary Electrical Box <br />Valve Frame <br />Valve Cover <br />.Other WxL <br />Piace Paver I Stone /Brick ~ <br />Traffic Marker Dots ea <br />Piug 1 y,"Gas Prospect Hole ea <br />inches <br />_inches <br />4'18"112'Crosswalk <br />ea <br />I <br />I <br />I <br />I <br />Striping <br />Paint <br />Thermoplastic <br />Traffic Legend <br />Double Center Lane <br />3M "Scotch Lane" <br />Slurry I Fog /Sand <br />Asphalt <br />Asphalt <br />Mill &Fill <br />Asphalt /Concrete Combo <br />Grind <br />Asphalt Fabric <br />Asphalt Benm/Curb <br />Saw Cut <br />Asphalt <br />Concrete <br />Seal <br />"ft'