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r -- <br />i <br />COUNTY OF SAN JUAQUIN <br />DEPARTMENT OF PULIC WORKS <br />Df�l1/I.l�fA1'S A,ND PAWED F[eiJNTAGES <br />PERWl� i�,PPLRC�iTiON <br />APPLICANT <br />Name: ,�. rr a,'l— �$�,_>` i f'R <br />Address: !� a,, ,3 a x �-z-��f �� <br />Cit ,State, Zi Code: � tc,Grst� s L'�- � �I j� 2"Z - <br />Area Code -Tele hone Number; '! - 'Z2 $ � Z S' `� `�' <br />SITE INFORMATION: <br />Parcel Owner's Name: � :�.� � �,,.� �,,�.,.��-�- <br />Site Address: >� 3 Z-� ��'-�- Ge. P-��f. <br />Cit ,State, Zi Code: err+-�< <�+. _ X30 � <br />Area Code -Tele hone Number: S! ` �- `�.� y- �cti ��, <br />CONTRACTOR <br />Name: rtz..rz�-r � �-� %�d-r <br />Address: <br />Cit ,State, Zi Code: <br />Area Code <br />-Tele <br />NOTES: <br />hone <br />Number; <br />Date: l r � �"�^ f `l <br />Received By: <br />CR#: <br />The undersigned hereby applies for permission to excavate, construct andlor otherwise encroach on County way Right -of -Way on the <br />/IIb+QTK side of l„AQGN 12D . approximately 23 t fe " mileFigS-S- <br />of Ce,�tAL �OG4d� Ra T.�A �+J , by installing Zai✓EwAy �q,gD�t{� <br />commence on or about <br />SKETCH <br />sheet may be submitted) <br />.�� �b �� <br />L�.�,:,,�-� <br />0 <br />for approximately <br />'' Will this project be self -installed? ,YES NO Contractor's License <br />P:IENCROACH>.1E�YTSIUasler Foims-TempleleslENCROACHAIENT PERMIT DRIVEWAY.doc (08108) <br />Work will <br />days. <br />f'S— I �I O "3 7�CP <br />OFFICE USE ONLY <br />JOB #: <br />11005 ISSUE DATE: <br />APN <br />2l2•(®0-23 FEE DUE: <br />EXP. DATE; <br />DRIVEWAYS; <br />STREET: <br />a. <br />AREA: <br />�,2,gcy QUAD <br />TYPE: <br />�2r ✓�wAr ick * <br />FORMS: <br />�,.�.v !? <br />NOTES: <br />DRIVEWAY <br />TYPE: <br />QUANTITY <br />WIDTHS <br />AGRICULTURE: <br />FRONTAGE <br />COMMERCIAL: <br />INDUSTRIAL; <br />RNV <br />RESIDENCE: <br />PAVED FRONTAGE <br />LENGTH: <br />Ft. X WIDTH: <br />Ft. <br />The undersigned hereby applies for permission to excavate, construct andlor otherwise encroach on County way Right -of -Way on the <br />/IIb+QTK side of l„AQGN 12D . approximately 23 t fe " mileFigS-S- <br />of Ce,�tAL �OG4d� Ra T.�A �+J , by installing Zai✓EwAy �q,gD�t{� <br />commence on or about <br />SKETCH <br />sheet may be submitted) <br />.�� �b �� <br />L�.�,:,,�-� <br />0 <br />for approximately <br />'' Will this project be self -installed? ,YES NO Contractor's License <br />P:IENCROACH>.1E�YTSIUasler Foims-TempleleslENCROACHAIENT PERMIT DRIVEWAY.doc (08108) <br />Work will <br />days. <br />f'S— I �I O "3 7�CP <br />