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COUNTY OF SAN JOAQUIN Date: $- 13 • �' <br /> DEPARTMENT OF PULIC WORKS <br /> Received By: k -�z <br /> DRIVEWAYS AND PAVED FRONTAGES <br /> PERMIT APPLICATION CR#: c,3F3 ,e <br /> APPLICANT OFFICE USE ONLY <br /> Name: f <br /> Address: JOB#: 11005 ISSUE DATE: <br /> City,State,Zip Code: - APNI FEE DUE: <br /> Area Code -Telephone Number: ;' � 7 EXP.DATE DRIVEWAYS: <br /> STREET: <br /> SITE INFORMATION: AREA: QUAD Yq— <br /> Parcel Owner's Name: r, f� TYPE <br /> Site Address: ? FORMS: 53 i.61 —t <br /> Cit ,State,Zip Code:-'lizNOTES: <br /> Area Code -Tele hone Number: <br /> DRIVEWAY <br /> CONTRACTOR TYPE: QUANTITY T WIDTHS <br /> Name: AGRICULTURE: I @FRONTAGE <br /> Address: COMMERCIAL: <br /> City, State,Zip Code: INDUSTRIAL: 0 R/W <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 otherwise encroach on County Highway Ri ht-of-Way on the <br /> side ofapproximately <br /> of AC* i%0,ky � by installing <br /> Work will <br /> commence on or about— for approximately days. <br /> SKETCH(Separate sheet may be submitted) <br /> I <br /> i <br /> J <br /> Will this protect be self-installed? _YES NO Contractor's License ' <br /> r, e5 .. e <br /> Y!fOFWS&TEMPLATES%ENC'ROACHMENi PERLM OAIVFWAY.da,1OW08) <br />