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APPLICATION FOR ENCROACHMENT PERMIT <br /> PLEASE PRINT: <br /> Date 01-29-2013 OFFICE USE ONLY <br /> To: San Joaquin County JOB# `jj REF# <br /> Department of Public Works APN CR# <br /> Advanced GeoEnvironmental EXP.DATE 3 <br /> VALID T ,� DRIVEWAYS: <br /> (Applicant Name) STREET <br /> 837 Shaw Road AREA �A,DD <br /> TYPE <br /> (Mailing Address) FORMS <br /> Stockton, CA 95215 NOTES <br /> (City,State,Zip Code) <br /> 209 467 1006 <br /> (Area Code-Telephone Number) <br /> Sketch(Detailed plans may be submitted) <br /> The undersigned hereby applies for permission to excavate,construct and/or otherwise encroach on County Highway Right-of-Way on <br /> the East side of North Wilson Way y <br /> of East Orwood Street approximately 200 feet/mile north <br /> by performing the following work(description of work): <br /> Work will commence on or about for approximately <br /> 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 /> 01-29-13 <br /> 3 <br /> Signature of Applicant-Title Date <br /> E:IPU&SV.WKIMASTER.PSIENCROACHMENTPERMIT APPLICATION.DOC (01/08) <br />