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COUNTY OF SAN JrOAQUIN <br /> DEPARTMENT OF PUBLICWORKS Received by <br /> DRIVEWAY AND PAVED FRONTAGES <br /> PERMIT APPLICATION <br /> APPLICANT OFFICE USE ON]l <br /> JOB#11005 ISS17E DATE / <br /> NameN-ZZ(:y - /Bo _ /(o FEE DUE <br /> EXP.DATE DRIVEWAYS: <br /> AddressSTREET_ -. _ i1A2)&A) AD, ' <br /> oz, S, 're.1 <br /> QUAD .515 • <br /> State-Zip Code TYPE X>IAD s <br /> FORMS_ SZJ�2+/7 6 <br /> (Area Code)Telephony OTE ND /Pt <br /> ZG �3 - /.vG5 <br /> SITE INFORMATION <br /> a,w, r <br /> Parcel Owner's Name / ' <br /> (2c� <br /> Site Address <br /> ria 'A ' X33 �7DRIVEWAY <br /> City,State-Zip Code TYPE QUANTITY. WIDE <br /> %3 AGRICULTURE @ FRONTAGE <br /> (Area Code)Telephone COMMERCIAL <br /> USTRLAL @ R/W <br /> NPSIODENCE �— <br /> CONTRACTOR PAVED FRONTAGE <br /> TIL_ Ft. X WIDTH: Ft. <br /> EGName <br /> Address The undersigned herebv—lies for permission to encroach cm['--w Highway <br /> Right-of-Way on the L0_"S 1 side or (zN!o+v +tD <br /> City,State-Zip Code approxima#e1y 300 Of_A <br /> �A _,by installing aw <br /> (Area Code)Telephone <br /> Work <br /> WW 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 /> locmgler Ap Tmm\aivewayPaved f rouge <br /> A <br />