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COUNTY OF SAN JOAQUIN <br /> DEPARTMENT OF PULIC WORKS Date: 3 2, <br /> DRIVEWAYS AND PAVED FRONTAGES Received By: '5�,f <br /> PERMIT APPLICATION <br /> APPLI ANT <br /> Name: <br /> Address: OFFICE USE ONLY <br /> - <br /> City, State,Zip Code: 6 JOB#: <br /> L (�. t y� Z 11005 ISSUE DATE: <br /> Area Code -Tele hone Num ber• APN <br /> " �Com ; — <br /> EXP. DATE: FEE DUE: <br /> DRIVEWAYS: <br /> SITE INFORMATION: STREET: <br /> Parcel Owner's Name: AREA: / QUAD it/F <br /> Site Address: 7Z�\ l' /7 TYPE: <br /> City, State,Zip Code. M� �til FORMS: <br /> Area code Telephone Number,12 NOTES: <br /> CONTRACTOR DRIVEWAY <br /> Name: TYPE: QUANTITY <br /> Address: AGRICULTURE: WIDTHS <br /> City, State, ip Code: COMMERCIAL: I @FRONTAGE <br /> Area Code -Telephone Number. INDUSTRIAL: <br /> _C,�' f', RESIDENCE: @ R/W <br /> PAVED FRONTAGE <br /> LENGTH: Ft. X WIDTH: <br /> Th nderslgned hereby applies for permis ion to excavate,construct and/or otherwise encroach on County Hi hwa Rig Ft. <br /> side of <br /> of '�' e Y 9h of Wa on the <br /> approximately � —� <br /> ,by installing <br /> commence on or about <br /> for approximately Work will <br /> SKETCH(Separate sheet may be submitted) days. <br /> Will this project be self-installed? YES <br /> __NO Contractor's License <br /> IISJPWGOV.ORGISHARESICENTRALSERVICESICLERICALIPUB-SV.WKIMASTER.PSIENCROACHMENTPERMITDRIVEWAY.DOC (10/09) <br /> Page 1 oft <br />