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APPLICATION FOR ENCROACHMENT PERMIT <br /> CONTINUED <br /> March 25, 2010 <br /> CBS13/CW 31/Shriners Hospital <br /> Attn: Mike Bal <br /> 2713 KOVR Dr <br /> West Sacramento, CA 95605 <br /> 916-374-1407 <br /> The undersigned hereby applies for permission to excavate,construct and/or otherwise encroach on County Highway Right-of-Way on <br /> the_ _side of approximately 34 __feeUmile <br /> of See roa-e above , by performing the following work(description of work): <br /> A go-cart drive as a fund raiser benefitting Shriners Children's Hospital. Description on page one) <br /> Work will commence on or about_April 9, 2010 for approximately 3 hours 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 ules and regulations of San Joaquin County and subject to inspection and approval. <br /> March 25, 2010 <br /> rgnature of A p pi 4nt-I i t I e Date <br /> I AY SSI YgAUCir 14&4 2']ACMl KT i TAPIA;TWX DOC (0:8741 <br />