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APPLICATION FOR ENCROACHMENT PERMIT <br /> PLEASE PRINT: <br /> Date 12/3/12 OFFICE USE ONLY <br /> To: San Joaquin County JOB# REF# <br /> Department of Public Works APN CR# <br /> EXP.DATE 11111-4 <br /> SSJID-Forrest Killingsworth VALID �?- 7 /F- TO/ DRIVEWAYS: <br /> (Applicant Name) STREET n �' <br /> AREA 0w QUAD <br /> P.O. Box 747 TYPE in <br /> (Mailing Address) FORMS , ' Z5' <br /> NOTES <br /> Ripon, CA. 95366 0747 <br /> (City,State,Zip Code) <br /> (209)249-4620 <br /> (Area Code-Telephone Number) <br /> Sketch(Detailed plans may be submitted) <br /> see attached plans <br /> e <br /> All gldl 4-1 <br /> The undersigned hereby applies for permission to excavate, construct and/or otherwise encroach on County Highway Right-of-Way on <br /> the south side of Jones Road in Escalon. CA approximately 30 feet <br /> of unpaved shoulder area and open space , by performing the following work(description of work): <br /> The work will consist of the removal and replacement of aP2roximately 50 lineal feet of existing 36"Irrigation and an existing <br /> irrigation control box adjacent to Jones Road. Pavement within Jones Road shall remain undisturbed. <br /> Work will commence on or about December 7.2012 for approximately 15 work 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 /> 1(J- -- 11,1 -6111- <br /> Signature <br /> 1, 3 1ZSignature o Applican -Title D to <br /> E tg16&t•t•7F1!.mE?ERF.IE�JCR�ACNtIEN?PEkA17 FPi'I�CA?fOH DOC 011M) <br />