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T1f E A ,rJ1Ac:ALV E rr bAbO i a.r as.>M JMo. <br /> 1. That he/she bas read all the provisions of this W ication,and that the description rocketed ietbis application are ooaect to the best of his/her <br /> knowhndge;and <br /> 2. That he/she is the owner of the respective property,or is Qualified to rrp the owner;and <br /> 3. That he/she will assume fall respeasibi*Sar all liability for personal sugury or damage to pmpedy which MY arise out Of&0 wodc described above, <br /> or which may arise out of his/her failure to do the worts pcovided herck and <br /> 4. That in the event aY claim of swch liabiMy is made agaifit*eCwm®ty of Sm A me ins or ahiy oflsciat or employee th er he shall <br /> defend,indemnify and holdthem and esch of then berm less for such claim,;and <br /> 5. That work shall be perfarowd by the apphcW and/or any repress tahive cf the applicant in she County Right-of-Way at the above indicated site <br /> with a valid San Joaquin County FAwroachmaut Pamfit;add <br /> b. That if permission is granted as recluadad,has agecm to do the wa>dc deembed it acocrdance with A teens,condition and restriction of Oris and any, <br /> attached ghee as geaerai III provisions• <br /> !�$�tgmtaraofElpp}i�at-Tilts C Date �p <br /> FIELD INSPECTOR COBOMM <br /> »»»»»»»»»»»»»»»»>}»»E=T1NG CONDMONS«««««««««««««««««««« <br /> L DRIVEWAY: None pica ❑ Gravel ❑ AMqp&Baso ❑ Paveb(gl")) ❑ Paved(Good) ❑ <br /> 2.SLOPING Away fvmpavement ❑ TowardsPavemaig ❑ Flat 4� <br /> 3.PIPES:. Now Esiaft-TYPO AAee�� <br /> OdWpipesinneigLbodM& Yes ❑ No us Approaches cross Dram, ❑ size <br /> Attachment tondg]t}m%pipe: Yea ❑ No ls.t <br /> 4.KKADWALL: Yea ❑ No <br /> S.ASPHALT CONCRETE Dl7tE:' Yes ❑ No <br /> 6..BARRUMS aloegRight-a&Way <br /> 1. DITCH Yes ❑ No IfYes:. V Style ❑ 2 Point ❑ Mer ❑ Width Depth <br /> »»>>>>> »»»»»»»»»»PERMTREQUiREMENTS«««««««««««««««««««« <br /> L DRIVEWAY: OR � COMUMCIAL ❑ AORIMMTW ❑ INDUSTRIAL. ❑ <br /> PAVED with ?j "Mm.Depth AC,over �' "Mn.Depth 3/4"AB <br /> Nates <br /> 2. PIPE& Length of Pipe Re'"irod:' FL sod Di=a.(Aw cf Pipe In& <br /> To be c000ected to any adjacent driveway pipe Yes ❑ No <br /> DRAINAt3E INLET REQUIRED Yea ❑ No <br /> Total Length: (vu!iffi proposed) Total Number of Shmm Drdi Inks <br /> Notes <br /> 3. HFADWALL Yes ❑Q No <br /> 4. PAVED FRONTAGE: PAVED with "Mm.Depth AC.over "hfiL Depth 3/4"A& <br /> Measuring Feet in tength and Feet in width <br /> FEES <br /> Driveway Encroachment Pewit base flee...................:...... 5. <br /> VFi 'onvr/or w/o pipe........_ _ __ 5_ ❑Paved AmUge....-..__.....:..._..__....S100.00+0.46)R <br /> w/boxCwlvaR._._. _...... _. _.. ..... _ ❑Curb,tkww,Sidewalk....:._...:...._.....$100:00+0.98M <br /> Counte&Compi ter,cAAccessVippiicefion for PcrmslDrit y and Paved Frontage Page.2 of 2 Revised 8/2000 <br /> t,� <br />