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09/07/2007 14:44 20946BS324 SJC0 PEP.MITS PAGE 02/03 <br /> APPLICATION FOR ENCROACF,IICM PERMIT <br /> PLEABE_PRINTa <br /> Date ng- 1 i-nj _ OFFIC8 ZYMN ONLY <br /> TO: San Joaquin County JOH #_ o o S REF # <br /> Department of Public works APN CR # <br /> KENNETH "MIKE" KELLOGG EIRP. DATE !� of o8 <br /> VFj'ILD d 2b o1 T4 110 01 OS DRIVEWAYS: <br /> (Applicant. Name) STREET AD *AREA 2= <br /> 8079 Blackwood Lane Tipp 0INI> Ay <br /> (Nailing Adds®s) F'OR.MB <br /> Roseville , CA 95747 NOTE <br /> (city, state, zip Cods) <br /> ( 916 ) 771 -0869 <br /> (Area Code - Telephone NUX&er) <br /> Sketch (]?etailed plans may be submitted) <br /> See approved plans . <br /> The undersigned hereby applies for Permission to excavate, construct and/or <br /> otherwieae encroach on Ccuaty-Eighway Right-Of-Way on the no r t h side of <br /> Mayer Road __ approximately 662 feet/mile East <br /> of T r e t h ewav Road_ ,Ac ar�n by-par€orming the <br /> following work (description of wor)".) : - add 4 ' 6" <br /> of 2" asphalt over 6" aggragate and 6 ' of 6 aygrag_a e ski—oul—der <br /> alonq 332 feet of existing road av t 11467 Mavers RoTd : ACarnpo . <br /> work will commenae on or ebout for approximately <br /> days. <br /> 1, the undersigned certify that I am the owner of the raspactive property, or am <br /> gtjaljZjQd to represent the owner and agree to do the work d.eacri.bed above in <br /> accordance with the rules, regulations of Ban Joaquin County and subje.ot to <br /> inspection and approval. <br /> Signature of Applicant - Title t® <br /> M7�gSstn.n�\trnnAomz lb/oaf <br />