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COUNTY OF SAN�JOAQUIN Date � /7 a�' <br /> DEPARTMENT OF PULIC WORKS —`— <br /> DRIVEWAYS At4D PAVED FRONTAGES Received By: <br /> PER tTAPPL1CATM CR#: <br /> APPLICANT OFFICE USE ONLY <br /> Name: _ <br /> Address: JOB#: 1105 ISSUE DATE: <br /> Cl ,State,Zi Code: APN 1'��03 -� — FEE DUE: <br /> Area Code -Telephone Number: EXP.DATE: DRIVEWAYS: <br /> STREET: 4v-d'e- <br /> SITE INFORMATION: AREA: 15r QUADS <br /> Parcel Owner's Name: /cf � TYPE: , <br /> Site Address: FORMS_ <br /> City,State,Zip Code: - NOTES: <br /> Area Code -Telephone Number: � � -- <br /> DRIVEWAY <br /> CONTRACTOR TYPE: QUANTITY WIDTHS <br /> Name: AGRICULTURE; AGE <br /> Address: CO�ERCtAL: <br /> _City,State,Zip Code: INDUSTRIAL; @ { <br /> Area Code -Telephone Number: RESIDENCE: <br /> PAVED FRONTAGE <br /> LENGTH: Ft. X WIDTH: Ft. <br /> The undersigned hereby applies for permission to excavate,construct and/or ofherwise encroach on County Hi Rift-of Way an the <br /> side of dD�Gd �9Y' . approximately 3�Ja ee t <br /> of Goss.ez fir` by installing stJ <br /> commence on or about for approximately days. Work will <br /> SKETCH(Separate sheet may be submitted) <br /> Will this protect be self-installed? YES NO Contractor's License <br /> Y,FORMS d TEMPLATESENCROACHWENT PERMIT DRIVEWAY.doc(%W) <br />