Encroachment Permit Application Checklist
Please complete items 1 through 30. Insert "N/A" in the item, if it does not apply to your project. Print your application single-sided and submit all of the applicable information identified in the Encroachment Permit Application Checklist.
All dimensions shall be in US Customary (English) Units.
|1-5||County, highway route number, highway postmile (location of work), address of work site (if property does not have an address, enter street or road name), and city or community.|
|6||Distance and the direction from the nearest cross street to the work site (e.g. 500 ft. north of C Street).|
|7||Portions of State right-of-way where work will occur (pavement, shoulder, back of curb, slope, ditch, etc.).|
|8||Indicate whether a contractor or your own forces will perform the work.|
|9-10||Estimate start and completion dates for the permit work.|
|11||Maximum depth, average depth, average width, and average length. Describe the existing highway surface type (concrete, asphalt, gravel, dirt, etc.) of the excavation area.|
|12||Estimate cost for all work to be done within the State right-of-way, and funding source(s).|
|13||Type of pipe or conduit material to be used and product (water, gas, etc.), the diameter, and voltage of electrical current or pressure of liquid or gas.|
|14||Project Code (ID) number if this is a State Project, capital project, or joint venture project.|
|15||Indicate if you are applying for a "Double-Permit" and list the "Parent Permit Number", your company's reference number, or utility work order number for this project.|
|16||Has another Caltrans branch seen or reviewed your plans? Name of Caltrans staff?|
|17||Describe the proposed work to be done entirely, if applicable, attach six(6) complete sets of plans, and each plan set must be collated, bound, and folded no larger than 12"x 18".|
Check "YES", if you are getting a permit or approval from another agency (City, County, etc.),and an environmental determination has been made. If your project is Exempt, then check the Categorically Exempt, Negative Declaration, Environmental Impact Report box if one has been prepared. Attach a copy of the approved document and a copy of the Notice of Determination.
If you check "NO", check the box of the appropriate type of work to be done, or check "Other" and fill in the work to be done.
|19||A historical resource includes, but is not limited to, any object, building, structure, site, area, place, record, or manuscript that has historical or archeological significance; or significance in the architectural, engineering, scientific, economic, agricultural, educational, social, political, military, or cultural annals of California.|
|20||In this context a Scenic Resource includes, but is not limited to, trees that display outstanding features of form and age; unique, massive rock formations; historic buildings that are rare examples of their period, style, design, of which have special architectural features and details of importance.|
|21||Is there any work being done on the applicant's property?|
|22||Indicate if the propose project will require the disturbance of soil. If "YES", estimate the area withinANDoutside of the State highway right-of-way in square feetANDacres.|
|23||Indicate if the proposed project will require dewatering. If "YES", estimate the volume in total gallonsANDgallons per month. Also, indicate the source(stormwater or non-stormwater, see Caltrans SWMP for definitions of non-stormwater discharge).|
|24||Indicate how many stormwater or groundwater will be disposed of from or near the limits of the proposed project.|
|25||Name of applicant, adjacent property owner, or organization applying for the permit. Provide e-mail address, the address where the permit is to be mailed, phone number, and fax number.|
|26||Name of the authorized agent or engineer. If signing on behalf of the applicant, owner, or organization, attach a letter of authorization signed by the applicant, owner, or organization. Provide e-mail address, mailing address, phone number, and fax number.|
|27-28||Signature shall be that of the applicant or applicant's authorized agent. (Page 2 of form with an original wet signature must be submitted.)|
|29||Title of signatory (owner, president, etc.).|
|30||Date of the signature.|