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COUNTY OF SAN JOAQUIN Date: _4/2,4/12— <br /> �►� DEPARTMENT OF PULIC WORKS / <br /> DRIVEWAYS AND PAVED FRONTAGES Received By: �- <br /> PERMIT APPLICATION CR#: —14 5 76 z, <br /> APPLICANT <br /> Name: K'. KI hc, I c-, SE ONLY <br /> ( Address: -v r77 <br /> City, State,Zip Code: Ur, ,jj _-,. .�� ISSUE DATE: <br /> �y53(i: <br /> Area Code -Telephone Number: r � FEE DUE: <br /> -3)L '; DRIVEWAYS: <br /> SITE INFORMATION: AREA: TQgcy QUAD <br /> Parcel Owner's Name- �� 1 Y I Sr. TYPE: Sw <br /> Site Address: �V <br /> Cit , State,Zi Code: .. FORMS: Ss <br /> - �> - C �\ i i3 L�t-1 NOTES- <br /> Area Code -Telephone Number. <br /> DRIVEWAY <br /> Name: <br /> CONTRACTOR TYPE: QUANTITY <br /> AGRICULTURE: WIDTHS <br /> Address: @FRONTAGE <br /> City,State,Zip Code: COMMERCIAL: <br /> Area Code -Telephone Number: INDUSTRIAL: @ R/W <br /> RESIDENCE: 4/ <br /> PAVED FRONTAGE <br /> LENGTH: Ft. X WIDTH: Ft. <br /> The undersigned hereby applies for permission to excavate,construct and/or otherwise encroach on County&Hinw�y Right-of--Way on the <br /> odside��'3RD ,�D, approximately ryoo <br /> by installing mit) <br /> commence on or about for approximately Work will <br /> days. <br /> 7(Separatee sheet may be submitted) <br /> Will this project be self-installed? YES NO Contractor's License <br /> IISJPWGOV.ORGISHARESICENTRALSERVICESICLERICALIPUB-SV.WKIMASTER.PSIENCROACHMENTPERMITDRIVEWAY.DOC (10/09) Pa e1of2 <br /> 9 <br />