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Pacific Gas aid Field Paving Form Permit Number: <br />Eloctric Company '° Permit Expiration he <br />F„ � <br />Date: .0 t"'� y� K Street Address:.,Jx��� � . '✓ ,[}'� �'ta;^ F�3 P� ' <br />Foreman Name: a' t^` ac''�B �P7 Cross Street: 'p,�a3 mPr <br />PM Number: s7i1 i City oun : <br />Concrete W x L Depth <br />Roadway _inches <br />Sidewalk _ inches Color: Y I N Aggregate: Y I N Decorative/Stamped: Y/ N <br />Sidewalk _ inches Color: Y I N Aggregate: Y/ N Decorative/Stamped: Y/ N <br />Driveway _ inches - Color: Y I N Aggregate: Y/ N DecorativelStamped: Y I N <br />Driveway _ inches Color: Y I N Aggregate: Y I N DecorativelStamped: Y/ N <br />Curb Ramp Domes: Y / N <br />Curb f Gutter Y111 <br />Valley Gutter If <br />Dowels ea Size: #41 #5 <br />Asphalt W x;L d Depth Adjust/Replace <br />sr e I <br />Asphalt y inches Manhole Frame ea <br />ill —& Fill _ inches Sidewalk Gas Valve Boxea <br />Asphalt / Concrete Combo _" over_" Secondary Electrical BoxHea <br />ea 13" x 24" 17" x 30" 24" x 36" <br />Grind _ inches Valve Frame ea 15" 1 23" <br />Asphalt Fabric Valve Cover 30" x 30" 32" x 32" 48" x 48" <br />Asphalt Berm / Curb If <br />Saw Cut Depth Other W x L <br />Asphalt [_37T�If, inches Place Paver / Stone 1 Brick In Concrete: Y I N <br />Concrete If inches Traffic Marker Dols as Reflective: Y / N <br />Seal W x L Plug 1 W Gas Prospect Hole as Concrete I Asphalt <br />Slurry I Fog I Sand W <br />Striping Width Notes <br />Paint If _ inches <br />Thermoplastic If _inches <br />Traffic Legend ea <br />Doubf',�pmer Lane If - <br />3M "Scotch Lane" If 4" 8" 112" Crosswalk <br />Rout W <br />i <br />C. L �'J / <br />