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APPLICATION FOR ENCROACHMENT PERMIT <br /> PLEASE PRINT: <br /> Date 12_7-06 OFFICE USE ONLY <br /> To: San Joaquin County JOB # 15005 REF # <br /> Department of Public Works APN '01A r CR' # <br /> EXP. DATE <br /> Golden Stat-p iTti 1 ity ro VALID !/3/02 TO DRIVEWAYS: <br /> (Applicant Name) STREET STR.eET * <br /> AREA Lupk' QUAD t-W <br /> 2007 W_T u o l >>m n P Rd - TYPE Y oM T Ke� <br /> (Mailing Address) FORMS SS�� R--21 <br /> NOTE <br /> T� r� 1 nck', CA 9 Fi 180 <br /> (City, State, Zip Code) <br /> 209) 6344981 <br /> (Area Code - Telephone Number) <br /> Sketch (Detailed plans may be submitted) <br /> SEE ATTACHED REFER TO DWG, ATTACHED <br /> The undersigned hereby applies for permission to excavate, construct and/or <br /> otherwise encroach on Countv Highway Right-of-Way on the North & Southside of Banner St. <br /> and West sir$ Of Star St. approximately 368 feet/mom <br /> of dirt. curb and quer and asphalt , , by performing the <br /> following work (description of work) : pjadng hz tri mAiinA arty 3dniatlay 300 fry c7f 4" <br /> gas RiPP mint and placing an r 3dmatelv 112 feet 2" = piper PMF 4" criyj,i -rd QC 4" t—I Ep r r a <br /> C=Int wc&being dale far: amw- Neil W. MzDmti al 4820 N_ Star St_ (n=Cityl Tedi (t� 99242 -925-M3-5560 <br /> Work will commence on or about 12-18-06 for approximately <br /> 45 days N7IE: 4u--rk cn 1xivate prcpa7y and the P[E will start 12--8-06 <br /> I, the undersigned certify that I am the owner of the respective property, or am <br /> qualified to represent'. the owner and agree to do the work described above in <br /> accordance with the rules, regulations of San Joaquin County and subject to <br /> in coon and approval. <br /> Signature of Applicant. - Title Date <br /> �TA2� N'6Lc.i5 <br /> MASTER.PS\PEES=L (6/00) <br />