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APPLICATION FOR ENCROACHMENT PERMIT <br /> PLEASE PRINT: <br /> Date 3-25-13 <br /> OFFICE USE ONLY <br /> To: San Joaquin County JOB# REF# <br /> Department of Public Works APN CR# <br /> Darin Jones EXP.DATE S <br /> VALID1, 1S 13 DRIVEWAYS: <br /> (Applicant Name) STREET 13 l ' T <br /> 850 Stillwater Road AREA QUAD 1-59 <br /> TYPE <br /> (Mailing Address) FORMS <br /> West Sacramento ca 95605 NOTES <br /> (City,State,Zip Code) <br /> 916-760-1953 <br /> (Area Code-Telephone Number) <br /> Sketch(Detailed plans may be submitted) <br /> See Attached Sketch <br /> The undersigned hereby applies for permission to excavate,construct and/or otherwise encroach on County Highway Right-of-Wayon <br /> the North side of West Ripon Rd approximately 1500 ' feet/mile Wet <br /> of Brown Rd. <br /> Replace existing pole with new pole. <br /> by performing the following work(description of work): <br /> Work will commence on or about 4-11-13 for approximately 1 <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 /> Signature of Ap licant-Title 3-25-13 <br /> Date <br /> E:IPU&SV.WKIMASTER.PSIENCROACHMENTPERMIT APPLICATION.DOC (01/08) <br />