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APPLICATION FOR ENCROACHMENT PERMIT <br /> PLEASE PRINT: <br /> Date NOVEMBER 8 2012 OFFICE USE ONLY <br /> To: San Joaquin County JOB# AW5— REF# <br /> Department of Public Works APN CR# <br /> SOUTH SAN JOAQUIN IRRIGATION DISTRICT EXP.DATE <br /> FORREST KILLINGSWORTH VALID TO DRIVEWAYS: <br /> (Applicant Name) STREET <br /> AREA QUAD <br /> 11011 EAST HIGHWAY 120 TYPE <br /> (Mailing Address) FORMS <br /> NOTES <br /> MANTECA, CA 95336 <br /> (City,State,Zip Code) <br /> (209) 249-4620 <br /> (Area Code-Telephone Number) <br /> Sketch(Detailed plans may be submitted) L <br /> CLOUGH AVENUE <br /> ENCROACHMENT <br /> CLOUGH ROAD <br /> EX. LAT. KAA w PROPOSED o <br /> IRR LINE <br /> D L-KAA PIPELINE <br /> N a CONNECTION <br /> z <br /> z <br /> = EX. LAT. L <br /> IRR LINE <br /> The undersigned hereby applies for permission to excavate,construct and/or otherwise encroach on County Highway Right-of-Way on <br /> theNORTH & SOUTHside of CLOUGH ROAD approximately 1,320 feet EAST <br /> Of MCHENRY AVENUE IN RURAL ESCALON , by performing the following work(description of work): <br /> INSTALLING SSJID 36" IRRIGATION LATERAL L-KAA CONNECTION WITH A PORTION OF THE CONNECTION WITHIN <br /> THE COUNTY RIGHT-OF-WAY. PROPOSED 36" PIPELINE WITHIN COUNTY RIGHT-OF-WAY SHALL BE CLASS IV R.G.R.C.P. <br /> Work will commence on or about 1 IZ113 for approximately 60 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 <br /> work described above in accordance with the rules and regulations of San Joaquin County and subject to inspection and approval. <br /> T-..� I/ J- Ass Ot,lATE Er4c2iq E - 9 f 12 <br /> Signature of Applicant-Title Date <br /> E%'IIB-FVYdN.N.NEAPS+E/1CGGFCNRHITPEPJATAPPIICATIONObC OIIYe) <br />