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COUNTY OF SAN JOAQUIN <br />DEPARTMENT OF PULIC WORKS <br />DRIVEWAYS AND PAVED FRONTAGES <br />PERMIT APPLICATION <br />Date:)-:;(J <br />Received By:T( <br />CR#:5'6/0 9' <br />Name:r2."'-Address:b <br />Ci ,State,Zi Code: <br />Area Code -Tele hone Number ,?o- <br />CONTRACTOR <br />Name: <br />Address: <br />Ci State,Zi Code: <br />Area Code -Tele hone Number: <br />The ~signed hereby applies <br />_~~~__side of <br />of C he/coKe'e <br />OFFICE USE ONLY <br />J08#:11005 ISSUE DATE: <br />APN DOC;2 ()(IJR FEE DUE:EXP,DATE:DRIVEWAYS: <br />STREET:a::;!4 ~d e Cf Q5A%l!~. <br />AREA:• <br />TYPE:1;/. <br />FORMS:fA/IA/17,'7 <br />NOTES:T <br />DRIVEWAY <br />TYPE:QUANTITY I WIDTHS <br />AGRICULTURE:I II!iIFRONTAGE <br />COMMERCIAL: <br />INDUSTRIAL:I I!iI RJIN <br />RESIDENCE: <br />PAVED FRONTAGE <br />LENGTH:Ft.X WIDTH:Ft. <br />ission to excavate,construct and/or otherwise encroach on County Hi way Right-of-Way on tl1e <br />I approximately eeU ile p________,byinstalling _ <br />___________________________________Workwill <br />commence on or about for approximately days, <br />SKETCH (Separate sheet may be submitted) <br />Will this project be self-installed?YES NO Contracto~s License _ <br />M'GENTRAlSERVlCESlClERlCAL'PUB-SV.WX\MASTERPS'CNCROACHIJCNT PERIIlr ORIVEWAV.DOC (01.08)Pagel 012