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COUNTY OF SAN JOAQUIN Date: I' Z _ jos <br /> DEPARTMENT OF PULIC WORKS <br /> Received By: <br /> DRIVEWAYS AND PAVED FRONTAGES <br /> PERMIT APPLICATION CR#: <br /> APPLICANT OFFICE USE ONLY <br /> • Name: ' - " ' - - ) f <br /> eF <br /> Address: p " JOB#: 11005 ISSUE DATE: <br /> City,State,Zip Code: to APN `4 FEE DUE: <br /> Area Code -Tele hone Number: , C4 EXP.DATE: DRIVEWAYS: <br /> STREET: <br /> SITE INFORMATIO h AREA: —QUADSr <br /> Parcel Owner's Name TYPE: <br /> Site Address: c 1,. FORMS: <br /> -City,StateZi Code: NOTES: <br /> Area Code -Telephone Number: <br /> DRIVEWAY. <br /> CONTRACT R n TYPE: QUANTITY WIDTHS <br /> ,Name: J AGRICULTURE: @FRONTAGE <br /> ddress: - COMMERCIAL: <br /> City,State,Zip Code: n - INDUSTRIAL: @ RM <br /> Area Code -Telephone Number: RESIDENCE: <br /> PAVED FRONTAGE <br /> LENGTH: Ft. X WIDTH: Ft. <br /> The undersigned hereby applies for permission to exc at ,construct and/or otherwise encroach on County Highway Right-of-Way on the <br /> W�S� side of approximately_V)_ fee >e � <br /> of by installing <br /> Work will <br /> commenc-"110n or about nor approximately days. <br /> SKETCH Separate sheet may be submitted);i <br /> �, <br /> Will this project be self-installed? _YES NO Contractor's Licensef t ! l M <br /> M:ICENTRALSERVICESICLERICALIPUB-SV.WKIMASTER.PSIENCROACHMENT PERMIT DRIVEWAY.DOC (09113) Page 1 of 2 <br />