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COUNTY OF SAN JOAQUIN Date: 28 <br /> DEPARTMENT OF PULIC WORKS <br /> DRIVEWAYS AND PAVED FRONTAGES Received By: <br /> PERMIT APPLICATION <br /> APPLICANT OFFICE USE ONLY <br /> Name: ( - <br /> Address: JOB#: 11005 ISSUE DATE: <br /> -City,State,Zi Code: ` APN '(® FEE DUE: <br /> Area Code Telephone Number. - G EXP.DATE: DRIVEWAYS: <br /> STREET: <br /> SITE INFORMATION: AREA: <br /> Parcel Owner's Name: ,�".,� TYPE: <br /> Site Address: _ FORMS: t <br /> City,State,Zip Code: c f" NOTES: <br /> Area Code -Telephone N ber: <br /> DRIVEWAY <br /> CONTRACTOR <br /> NameTYPE: QUANTITY WIDTHS <br /> : AGRICULTURE; <br /> Address: FRONTAGE <br /> City,State,Zip Code: COMMERCIAL: <br /> Area Code Telephone Number Area @ R/W <br /> 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 Rtht-of-Way on the <br /> side of approximately feet/mile <br /> of <br /> -- by installing <br /> commence on or about for approximatelydays. Work will <br /> SKETCH(Separate sheet may be submitted) <br /> Will this project be self-inQt Iled? VIES <br /> NO Contractor's License <br /> Y tFoPMcY TcVP I A rFS''FIJ(;,r1-WAr T W;'?lt ijRfV'WAI <br />