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APPLICATION FOR ENCROACHMENT PERMIT <br /> PLEASE PRINT: <br /> Date April 25,2012 - <br /> OFFICE USE ONLY <br /> r <br /> To: San Joaquin County JOB# //0041j REF# <br /> i Department of Public Works APN CR# <br /> 1 Cardno ERI EXP,DATE . ..... <br /> VALID / Z_',:0_ 7 fS. ;. .'DRIVEWAYS: .; <br /> (Applicant Name) STREET L1 A1A. <br /> 601 North McDowell Blvd. AREA UA -_.-, <br /> 5 <br /> (Mailing Address) TYPEFORMS , /A <br /> Petaluma, CA 94954 NOTES <br /> [ (City,State,Zip Code) _ <br /> .(707) 766 .2000 �ft <br /> II (Area Code_-Telephone Number) <br /> f Sketch (Detailed plans maybe suoinitted) ' <br /> 1 See attached site map and photo for groundwater monitoring well locations. <br /> i <br /> The undersigned hereby applies for permission to excavate, construct and/or otherwise encroach on County Highway Right-of-Way on <br /> the East sideof Hwy. 99 Frontage Road approximately 101feet/mile ' south ' <br /> Of the intersection.or E. Cahmayrna and Hwy 99 Frontage Ra, _. by performing the following work(description of work): <br /> Destruction of three monitoring wells (MWS:, MW9- & MW10) bypressuregrouting -and <br /> and over drill top 5 feet . - <br /> Work will commence on or about Ju y .2012 for approximately 2.-3 business 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 I <br /> ( work described above in accordance with the,rules and regulations of San Jdaquin`Counly'and subject to inspection and approval. <br /> y-3a-l�-- <br /> t{r - ) get re of Applicant-T e - - Date - <br /> i EwuB5v.R9{1W91t,F`!K.I!<0.90t.1i':iM:�ER191A0RICAIpHfAC PI.. \- i <br /> 1 i <br /> i <br /> i <br />