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COUNTY OF SAN JOAQUIN Date: Z- <br /> ' DEPARTMENT OF PULIC WORKS <br /> Received By: <br /> DRIVEWAYS AND PAVED FRONTAGES <br /> PERMIT APPLICATION CR#: L �3a�o <br /> APPLICANT OFFICE USE ONLY <br /> Name: 1, UCG <br /> Address: ` Nin A JOB#: 11005 ISSUE DATE: <br /> City,State,Zip Code: ' c (4 APN D417-23o-// FEE DUE: <br /> Area Code -Telephone Number: EXP. DATE: DRIVEWAYS: <br /> STREET: <br /> SITE INFORM TION: AREA: Lam/, ' QUAD <br /> Parcel Owner's Name:, L j}( TYPE: <br /> Site Address: FORMS: <br /> City,State,Zip Code: L ,f� C NOTES: <br /> Area Code -Telephone Number: rC1 <br /> DRIVEWAY <br /> CONTRACTOR TYPE: QUANTITY WIDTHS <br /> Name: AGRICULTURE: @FRONTAGE <br /> Address: COMMERCIAL: �C <br /> City,State,Zip Code: .. INDUSTRIAL: @ RNV <br /> Area Code -Telephone Number: RESIDENCE: <br /> PAVED FRONTAGE <br /> LENGTH: Ft. X WIDTH: Ft. <br /> The undersigned hereby appli'-e for permission to excavate,construct and/or otherwise encmAo on Count&HI ay Right-of-Way on the <br /> o�,� side of l��nlE41qu Ger/ approximately O j 11r <br /> of by installing <br /> Work will <br /> commence on or about for approximately days. <br /> SKETCH(Separate sheet may be submitted) <br /> Will this project be self-installed? YES NO Contractor's License <br /> IISJPWGOV.ORGISHARESICENTRALSERVICESICLERICALIPUB-SV.WKWIASTER.PSIENCROACHMENT PERMIT DRIVEWAY.DOC (10/09) Page 1 of 2 <br />