STATE OF CALIFORNIA • DEPARTMENT OF TRANSPORTATION Page 1 of 4
STANDARD ENCROACHMENT PERMIT APPLICATION FOR CALTRANS USE TR-0100 (REV 12/2018) TRACKING NO.
omplete ALL fields, write "N/A" if not applicable. Type or print clearl his application is not complete until all requirements have been approvec DIST/CO/RTE/PM Permission is requested to encroach on the State Highway right-of-way as follows:
SIMPLEX STAMP
1. COUNTY 2. ROUTE T3. POST MILE
Merced 59 14.78-14.35
4. ADDRESS OR STREET NAME 5. CITY
Martin Luther King Jr Wau Merced
6. CROSS STREET (Distance and direction from project site) DATE OF SIMPLEX STAMP Hwy 99
7. WORK TO BE PERFORMED BY 8. IS THIS APPLICATION FOR THE CONTRACTOR'S (DOUBLE) PERMIT? • APPLICANT • CONTRACTOR • NO • YES. If "YES", provide the Parent Permit Number
9. ESTIMATE START DATE 10. ESTIMATED COMPLETION DATE
5-19-2022 05/22/2022
11. ESTIMATED NUMBER OF WORKING DAYS WITHIN STATE HIGHWAY RIGHT-OF-WAY
12. ESTIMATED CONSTRUCTION COSTS WITHIN STATE HIGHWAY RIGHT-OF-WAY
13. HAS THE PROJECT BEEN REVIEWED BY ANOTHER CALTRANS BRANCH? X NO • YES. If "YES", which branch?
14. FUNDING SOURCES)
• FEDERAL • STATE • LOCAL • PRIVATE • SB 1 (ROAD REPAIR AND ACCOUNTABILITY ACT OF 2017)
15. CALTRANS PROJECT CODE (ID) 16. APPLICANT'S REFERENCE / UTILITY WORK ORDER NUMBER
17. DESCRIBE WORK TO BE DONE WITHIN STATE HIGHWAY RIGHT-OF-WAY (in 20 lines or less) Attach 6 complete sets of plans (folded to 8.5"x 11") and any applicable specifications, calculations, maps, traffic control plans, etc.
The march will be Saturday June 18th, 2022 on Martin Luther King Jr Way, (HWY 59). The route will begin at Martin Luther King Jr Way at W 18th St, and proceed south on Martin Luther King Jr Way to W 11th St, turn west on W 11th to K St. (McNamara Park). The march will begin at 10:00 AM and end approximately 11:00 AM. The march will only use the southbound lanes of Marting Luther King Jr Way. Merced Police Department will conduct rolling street closure with marked vehicles and staff at the front, rear, and all side streets. The expected turnout of this event is 200 people marching.
18 (a). PORTION OF STATE HIGHWAY RIGHT-OF-WAY WHERE WORK IS BEING PROPOSED (check all that apply) • Traffic lane • Shoulder • Sidewalk • Median [ At or near an intersection• Mobile work • Outside of the shoulder, feet from edge of pavement • Other 18 (b). PROPOSED TRAFFIC CONTROL PLANS AND METHOD
• No traffic control needed • State Standard Plans (T-Sheets) # X Project specific Traffic Control Plans included • To be submitted by contractor Copyright 2018 California Department of Transportation. All rights reserved STATE OF CALIFORNIA • DEPARTMENT OF TRANSPORTATION Page 2 of 4
STANDARD ENCROACHMENT PERMIT APPLICATION TRACKING NO
TR-0100 (REV 12/2018)
MAX. DEPTH (in) MIN. DEPTH (in) AVG. WIDTH (in) LENGTH (ft) SURFACE TYPE (e.g. Asphalt, concrete, soil, etc.)
EXCAVATION N/A
PRODUCT BEING TRANSPORTED CASING PIPE
PIPES N/A DIAMETER N/A_ (in.) MATERIAL N/A DIAMETER N/A (in.) MATERIAL N/A PROPOSED INSTALLATION METHOD (e.g. HDD, Bore & Jack, Open Cut, etc.) VOLTAGE / PSIG DOES THE PROPOSED PROJECT INVOLVE THE REPLACEMENT AND/OR ABANDONMENT OF AN EXISTING FACILITY? • NO [YES. If "YES", provide a description
21. IS A CITY, COUNTY OR OTHER PUBLIC AGENCY INVOLVED IN THE APPROVAL OF THIS PROJECT? • YES (if "YES", check the type of project AND attach the environmental documentation and conditions of approval) • COMMERCIAL DEVELOPMENT • BUILDING • GRADING • OTHER
• CATEGORICALLY EXEMPT • NEGATIVE DECLARATION • ENVIRONMENTAL IMPACT REPORT OTHER • NO (if "NO", check the category below which best describes the project AND answer questions A-K) • DRIVEWAY OR ROAD APPROACH, RECONSTRUCTION, • FENCE • EROSION CONTROL
MAINTENANCE OR RESURFACING
• PUBLIC UTILITY MODIFICATION, EXTENSIONS, HOOKUPS • MAILBOX • LANDSCAPING X FLAGS, SIGNS, BANNERS, DECORATIONS, PARADES AND CELEBRATIONS • OTHER The following questions must be answered when a City, County or other public agency IS NOT involved in the approval of this project.
Your answers to these questions will assist Caltrans staff in identifying any physical, biological, social or economic resources that may be affected by your proposed project within State Highway right-of-way and to determine which type of environmental studies may be required to approve your application for an encroachment permit. It is the applicant's responsibility for the production of all required environmental documentation and supporting studies and in some cases this may be costly and time consuming. If possible, attach photographs of the location of the proposed project. Answer these questions to the best of your ability. Provide a description of any "YES" answers (type, name, number, etc.).
A. Will any existing vegetation and/or landscaping within State Highway right-of-way be disturbed? No
B. Are there waterways (e.g. river, creek, pond, natural pool or dry streambed) adjacent to or within the limits of the proposed project? No
C. Is the proposed project located within five miles of the coast line? No
D. Will the proposed project generate construction noise levels greater than 86 decibels (dBA) (e.g. Jack-hammering, pile driving)? No
E. Will the proposed project incorporate land from a public park, recreation area or wildlife refuge open to the public? F. Are there any recreational trails or paths within the limits of the proposed project? G. Will the proposed project impact any structures, buildings, rail lines or bridges within State Highway right-of-way? Yes
H. Will the proposed project impact access to any businesses or residences? I. Will the proposed project impact any existing public utilities or public services? J. Will the proposed project impact any existing pedestrian facilities, such as sidewalks, crosswalks or overcrossings? K. Will new lighting be constructed within or adjacent to State Highway right-of-way? ADA Notice or individuals with sensory disabilities, this document is available in alternate formats. For alternate format information, contact the Forn anagement Unit at (916) 445-1233. TTY 711. or write to Records and Forms Management. 1120 N Street. MS-89, Sacramento. CA 9581 STATE OF CALIFORNIA • DEPARTMENT OF TRANSPORTATION Page 3 of 4 STANDARD ENCROACHMENT PERMIT APPLICATION TRACKING NO.
TR-0100 (REV 12/2018)
22. Will the proposed project cause a substantial change in the significance of a historical resource (45 years or older), or cultural resource? • YES • NO (if "YES", provide a description)
23. Will the proposed project be on an existing State Highway or street where the activity involves removal of a scenic resource? (e.g. A significant tree or stand of trees, a rock outcropping or a historic building) • YES X NO (if "YES", provide a description)
24. Is work being done on the applicant's property in addition to State Highway right-of-way? • YES X NO (If "YES", attach 6 complete sets of site and grading plans)
25. Will the proposed project require the disturbance of soil? • YES A NO If "YES", estimate the area of disturbed soil within State Highway right-of-way in acres:
and estimate the area of disturbed soil outside State Highway right-of-way in acres:
26. Will the proposed project require dewatering? • YES X NO If "YES", estimate Total gallons AND gallons/month. (Total gallons) AND (gallons/month.
SOURCE*: • STORMWATER • NON-STORMWATER
(*See Caltrans SWMP for definition of non-storm water discharge: http://www.dot.ca.gov/env/stormwater/)
27. How will any storm water or ground water be disposed? • Storm Drain System • Combined Sewer / Stormwater System Stormwater Retention Basin 2 N/A • Other (explain)
DA Notice For individuals with sensory disabilities, this document is available in alternate formats. For alternate format information, contact the Form anagement Unit at (916) 445-1233, TTY 711, or write to Records and Forms Management. 1120 N Street, MS-89. Sacramento, CA 9581.
STATE OF CALIFORNIA • DEPARTMENT OF TRANSPORTATION Page 4 of 4
STANDARD ENCROACHMENT PERMIT APPLICATION TRACKING NO
TR-0100 (REV 12/2018)
READ THE FOLLOWING CLAUSES PRIOR TO SIGNING THIS ENCROACHMENT PERMIT APPLICATION.
The applicant's submission of this application to the California Department of Transportation constitutes the applicant's agreement and representation that the work or other activity contemplated by the encroachment permit application shall comply with all applicable standards, specifications, policies, requirements, conditions, and regulations of the California Department of Transportation, and the applicant understands the application may be denied if there is non-compliance with any of the above. An exception process exists and may result in approval of a non-compliant encroachment, in the discretion of the California Department of Transportation, but the exception process may require additional time to complete. The applicant understands and agrees all work or other activity contemplated by the encroachment permit application is subject to inspection and oversight by the California Department of Transportation. The applicant understands and agrees encroachment permit fees must still be paid if an application is withdrawn or denied. The applicant understands a denial may be appealed, in accordance with California Streets and Highways Code, Section 671.5, and the related regulations found in California Code of Regulations, Title 21, Division 2, Chapter 8, Article 2.
The applicant understands and agrees that immediately upon issuance of the encroachment permit the applicant is bound by, subject to, and must comply with the "Encroachment Permit General Provisions" (TR-0045), "Stormwater Special Provisions" (TR-0400) and any other applicable Special Provisions and Conditions of the encroachment permit. The "Encroachment Permit General Provisions" (TR-0045), and the Stormwater Special Provisions (TR-0400) are available at: http://www.dot.ca.gov/trafficops/ep/docs/Appendix_K_(WEB).pdf. If a paper copy is needed of the "Encroachment Permit General Provisions" (TR-0045) and/or "Stormwater Special Provisions" (TR-0400), please contact the District Office of Encroachment Permits. Their contact information is available at: http://www.dot.ca.gov/trafficops/ep/docs/ Appendix_G_(WEB). pdf. The "Encroachment Permit General Provisions" (TR-0045) and any other applicable Special Provisions and Conditions will be provided as part of the encroachment permit. Information about Stormwater requirements is available at the Internet address:
http://www.dot.ca.gov/hq/construc/stormwater/.
The applicant understands an encroachment permit may be denied, revoked, and/or a bond may be required, for non-payment of prior or present encroachment permit fees. An encroachment permit is not a property right and does not transfer with the property to a new owner.
Each of the persons purporting to execute this application on behalf of the applicant and/or on behalf of the applicant's authorized agent or engineer represents and warrants such person has full and complete legal authority to do so and to thereby bind applicant to the terms and conditions herein and to the terms and/or conditions of the encroachment permit. Applicant understands and agrees this application may be executed in one or more counterparts, each of which shall be deemed an original, but all of which together shall constitute one and the same instrument. Executed copies of this application and/or its counterparts may be reproduced and/or exchanged by copy machine, mailing, facsimile, or electronic means (such as e-mail), and such copies shall be deemed to be effective as originals.
28. NAME OF APPLICANT (Project or Property Owner or Organization) City of Merced
ADDRESS OF APPLICANT (Include City, State and Zip Code) 611 W 22nd St, Merced CA 95340
E-MAIL ADDRESS PHONE NUMBER FAX NUMBER
[email protected] 209-769-6996 209-385-8880
29. NAME OF AUTHORIZED AGENT / ENGINEER IS A LETTER OF
(A "Letter of Authorization" is required if different from #28) AUTHORIZATION ATTACHED? Sgt Nathan McKinnon • YES X NO
ADDRESS OF AUTHORIZED AGENT / ENGINEER (Include City, State and Zip Code) 611 W 22nd St, Merced CA 95340
E-MAIL ADDRESS PHONE NUMBER [FAX NUMBER
[email protected] 209-796-6996 209-385-8880
30. NAME OF BILLING CONTACT (Same as #28 • Same as #29X) BILLING ADDRESS WHERE INVOICE(S) IS / ARE TO BE MAILED (Include City, State and Zip Code)
E-MAIL ADDRESS PHONE NUMBER FAX NUMBER
submitted with or in support of this application are true and correct to the best of my knowledge and belief, and that copies of any documents submitted with or in support of this application are true and correct copies of unaltered original documents. I further understand that if I have provided information that is false, intentionally incomplete, or misleading I may be charged with a crime and subjected to fine or imprisonment, or both fine and imprisonment. (Penal Code Section 72)
31. SIGNATURE OF APPLICANT OR AUTHORIZED AGENT* 32. PRINT OR TYPE NAME Nathan McKinnon Digitally signed by Nathan McKinnon Sgt Nathan McKinnon Date: 2022.05.23 14:28:34-0700
33. TITLE |34. DATE
Traffic Sergeant 5-23-2022
ADA Notice or individuals with sensory disabilities, this document is available in alternate formats. For alternate format information, contact the Forr anagement Unit at (916) 445-1233. TTY 711. or write to Records and Forms Management. 1120 N Street. MS-89 Sacramento. CA 9581 STATE OF CALIFORNIA • DEPARTMENT OF TRANSPORTATION
STANDARD ENCROACHMENT PERMIT APPLICATION
TR-0100 (REV 12/2018)
INSTRUCTIONS
Complete ALL fields, write "N/A" if not applicable. Type or print clearly. All dimensions must be in U.S. Customary (English) units.
Print your application single sided and submit all of the required attachments (See Section VII A&B of the "Encroachment Permit Application Guide Booklet" found at: http://www.dot.ca.gov/trafficops/ep/docs/EP_Application_Guide_Booklet.pdf).
1. County (e.g. Fresno, San Francisco, Los Angeles, etc.) Replacement and/or abandonment of an existing facility (e.g. Abandoning pipe and filling it with two-sack slurry cement)
2. State Highway Route Number (e.g. I-5, SR-99, etc.)
21. Check "YES", if you are getting a permit or approval from another agency
3. Highway Postmile: (location of work, see https://postmile.dot.ca.gov/) (City, County, etc.), and an environmental determination has been made.
If unable to determine, contact the appropriate District Encroachment Then check the Categorically Exempt, Negative Declaration, Permits Office for assistance at: http://www.dot.ca.gov/trafficops/ep/ Environmental Impact Report box or Other if one has been prepared docs/Appendix_G_(WEB).pdf Attach a copy of the approved document and a copy of the Notice of Determination. Skip questions A-K.
4. Address of project site (if the property has a physical address with a If you checked "NO", check the box of the appropriate type of work to be Number and Street/Road Name) done, or check "other" and fill in the type of work to be done. Also answer questions A-K.
5. City (e.g. Sacramento, Redding, Irvine, etc.)
22. A Historical Resource includes, but is not limited to, any object, building,
6. Distance and the direction from the nearest cross street to the project structure, site, area, place, record, or manuscript that has historical or site (e.g. 500 ft. north of "C" Street). archaeological significance, or significance in the architectural, engineering, scientific, economic, agricultural, educational, social, political, military, or
7. Indicate whether the work will be performed by the applicant (your own cultural annals of California. forces) or by a contractor.
23. In this context a Scenic Resource includes, but is not limited to, trees
8. Indicate if you are applying for a "Contractor's (Double) Permit" and that display outstanding features of form or age; unique, massive rock provide the "Parent Permit Number". formations; historic buildings that are rare examples of their period, style,
9. Estimated start date for the proposed work. (Allow a minimum of 60 design, or which have special architectural features and details of importance.
calendar days from the submittal date of your application for processing)
24. Is there any work being done on the applicant's property?
10. Estimated completion date for the proposed work.
25. Indicate if the proposed project will require the disturbance of soil. If "YES."
11. Estimated number of working days within State Highway right-of-way. estimate the area within AND outside of State Highway right-of-way in acres.
12. Estimated construction costs for all work to be done within State Highway right-of-way. 26. Indicate if the proposed project will require dewatering. If "YES," estimate volume in total gallons AND gallons per month. Also indicate
13. Has another Caltrans' branch seen or reviewed your project? Which the source: Stormwater or Non-Stormwater (see Caltrans Stormwater branch? (e.g. Design, Project Management, Right-of-Way, Management Plan for definitions of non-stormwater discharge at:
Environmental, etc.)
http://www.dot.ca.gov/hq/env/stormwater).
14. Identify funding sources) for the proposed work. 27. Indicate how any stormwater or ground water will be disposed of from or near the limits of the proposed project.
15. Caltrans' Project Code (ID) if this is a State project, capital project, or joint venture project. 28. Name of the applicant or organization applying for the permit. List the mailing address, e-mail address, phone and fax numbers.
16. Your company's reference number or utility work order number for this project. 29. Name of the authorized agent or engineer acting on behalf of the applicant or organization. Attach a letter of authorization signed by the
17. Describe the proposed work to be done entirely. If applicable, attach six (6) complete sets of FOLDED plans (folded 8-½" X 11") and any apolice no far numeron: List the maling address, e-mail addres. applicable specifications, calculations, maps, etc.
30. Name of the billing contact. List the mailing address where invoices
18. (a) Identify portion(s) of State right-of-way where work will occur and are to be mailed, email address, phone and fax numbers (b) proposed traffic control plans to be used if any.
31. Signature of the applicant or applicant's authorized agent.
19. Maximum and minimum depth, average width, and length of the excavation area. Existing surface type (e.g. Asphalt, concrete, soil, etc.) 32. Name of the applicant or applicant's authorized agent.
20. Product being transported (e.g. water, natural gas, etc.) 33. Title (owner, president, etc.) of the applicant or applicant's authorized Carrier pipe, diameter (inches) and material (e.g. Steel, HDPE, etc.) agent.
Casing pipe (if any), diameter and material Proposed installation method, Voltage of electrical current or pressure of liquid or gas. 34. Date of the signature.
For individuals with sensory disabilities, this document is available in alternate formats. For alternate format information, contact the Forms ADA Notice
Management Unit at (916) 445-1233, TTY 711, or write to Records and Forms Management, 1120 N Street, MS-89, Sacramento, CA 95814.