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+�a1se� <br />�t6C� PERMIT NUMBER: <br />CITY OF MANTECA <br />ENCROACHMENT PERMIT FORM <br />Mailing Address: Phone (209) 456-8580 <br />Community Development Department <br />1001 W. Center St., Suite. C Email engpermits@ci.manteca.ca.us <br />Manteca, CA 95337 <br />COMPLETE ITEMS 1 THORUGH 5 AND WRITE INITIALS ON PAGE 2 <br />j 1. PROJECT INFORMATION 5. PERMITTEE'S SIGNATURE _ <br />SR99-SR120Interchan e <br />Project Name � 9 Please read this permit carefully. Keep at the work site. To arrange <br />See attached maps for an inspection, call (209) 639-5964 or (209) 923-0528 at least 48 <br />Address or APN p hours prior to construction. <br />Project Location See attached maps <br />This permit is to be strictly construed and no work, other than that <br />2. PERMITTEE INFORMATION specifically mentioned in this permit, is hereby authorized. <br />Contractor Name : Blackburn Consulting <br />Phone (916) 375-8706 <br />E-mail danielc@blackbummnsulting.com <br />License Number : <br />Business Address: 2491 eoatmanAve, West Sacramento, 95691 <br />3. SCOPE OF WORK <br />D-riH 8 borings rangir q frOfrL.5 ta_8G_feeLdeep_ <br />for geotech soil samples. 1 bol7ng per location <br />shown on map. Holes will be 2"-6" in diameter. <br />4. WORK DETAILS <br />Tentative Start Date <br />Tentative End Date <br />Total Working days requested <br />❑ TRENCH <br />Total Length(s) (ft): <br />Maximum Depth(s) (ft): - <br />March 4,_2019 <br />March 18, 2019 <br />4 <br />❑ CURB/GUTTEWSIDEWALK REPAIR <br />Total Repair Length (ft): <br />PE TTEE'S SIGNATURE DATE <br />APPROVED (Yes/No) <br />License <br />✓ <br />Insurance <br />Traffic Control Plan <br />Monument Preservation <br />Moratorium <br />General Provisions/City Notes <br />t/ <br />Microsurfacing/Cape Seal Required? <br />Fee Required S �/7 Q� <br />►� <br />ENGINEERING DEPT. <br />X RECOMMENDED FOR APPROVAL DATE <br />WORK COMPLETED <br />INSPECTOR <br />DATE <br />Permit Not Valid Unless Executed by the City Engineer or an <br />authorized agent. <br />NOTES <br />5-borings-wilt-be,aduanced-with---drill-4g,3-wither-CP—T rig-, ander_with-hand_auger_ec uipmenL-H1-, <br />82, and CPT -1 will be 80' deep. The rest will be 5-10' deep. <br />n:soachment Permit Form August 2018 <br />Page 1 of 2 <br />