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COUNTY OF SAN JOAQUIN Date: <br /> DEPARTMENT OF PUBLIC WORKS Received by_ <br /> CR# <br /> DRIVEWAY AND PAVED FRONTAGES <br /> PERAHT APPLICATION <br /> APPLICANT OFFICE USE ONLY <br /> (h 1C 11 SEL C-M l wi JOB#11905 ISSUE DATE <br /> Name N -/�00 _D3 FEE DUE <br /> 6 N N .DATE DRIVEWAYS: <br /> K Address 3 ` STREET AREA /Aw QUAD_ » <br /> ' City,State-Zip Cale TYPE <br /> a°1FORMS 55 <br /> (Area Code)Telephone NOTE <br /> SITE INFORMATION <br /> G-bvi S C-qysty -T <br /> Parcel Owner'q Vame <br /> Site Address S3 6 DRIVEWAY <br /> / TYPE QUANTITY WIDTHS <br /> City,Age-Zip Cods <br /> _ AGRICULTURE Q FRONTAGE <br /> (Area Code)Telephone COMMERCIAL <br /> USTRIAL @ R/W <br /> rSIDENCE ✓ <br /> CONTRACTOR PAVED FRONTAGE <br /> _ LENGTH: Ft. X WIDTH: Ft. <br /> Name <br /> Address The undersigned hereby applies for permission to encroach on County Highway <br /> Right-of-Way on the X AST side(.f - T QJE RD, <br /> City,State-Zip Code approximately — feet/mile.ekim/ctom—of 6469WT <br /> by installing <br /> (Area Code)Telephone <br /> Work <br /> will commence on or about for approximately days. <br /> SKETCH(Separate sheet may be submitted) <br /> Will this project be self-installed? _NO YES Contractor's License <br /> Accros\Per App\FormlDrivewayPaved fi muge <br />