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THE AYYLI(.AiN 1 nr ru n z %—PLA r.. — <br /> I. That he/she has read all the provisions of this Mffica&4 and that the,description included iathis application are coned to the best of Iris/her <br /> knowfWdge;and <br /> 2. Ther he/she is the owner ofthe respective property,or is qualified to rgKesmt the owne4 and <br /> 3. That he✓she will assume full respondWitY for all liability&upersonai injuryordaamp to property which may arise out ofthe work described above, <br /> or which may atise out of his/her failure to do the work provided herein,and <br /> 4. That in the event any cWM of such habikiiy is made against tlteCcumty of San Jhagam or any dam,official err employee iheaeog he shall <br /> defend,indemnifjr and hold*=and each ad d m harmless for such clam;and <br /> S. That work shall be performed by the applicant and/or any representative of the applicant in the County Right-of-Way at the above indicated site <br /> with a valid San Joaquin County Facroadrmeat Permit;and <br /> 6. That if parmissior<is granted as requested,he agrees to do the work domed in acoordance with all terms,ocnditk ms and ttshidion ofth6 and any <br /> attached sheet,inchtded as general or special Iii provisions. <br /> Sigt atme of App)icaat-Me Date <br /> FIELD INSPECTOR COAMENTS <br /> »»»»»»»»»»»»»»»»>}»»VaSTING CONDITIONS«««««««««««««««««««« <br /> L DRAMWAY: NOW Dat ❑ t3ravel ❑ Aggregate Base ❑ Paved(poor) ❑ Paved(Good) ❑ <br /> 2.SLOPING: Awayfiom Paver--t ❑ Towuda Pavaememt ❑ Flat <br /> 3.,PIPES:. Now j-- Bad-Type <br /> Othorpipes inneighbathood: Yes ❑ No 61M Approaches 0 Cross Drain ❑ S= <br /> Attadmratt to neigle w%pgfe: Yes ❑ No <br /> 4.HEADWALL: Yes ❑ No' �. <br /> S ASPHALT CONCRETE DIICE:' Yea C❑ No <br /> 6..BARRIERS ak"Right-cWay <br /> 7. DITCH Yes ❑ No If Yew. V Style ❑ 2 Print ❑ Odw ❑ Wift Depth <br /> »»»»»»»»»»»»»»»»»»PBRMITREQUIREMENT3<z««««««««««««««««««« <br /> L DRIVEWAY: SFR COMMERCIAL ❑ At:#RfCUI.TUR$ ❑ INDUSTRIAL ❑ <br /> PAVED with �Z 'I f n.Depth A.C.over "Mm.Del&3/4"A.B. <br /> Notes <br /> 2.PEM& Length of Pipe Roq%jrod: Pt.and Diamaater of Pipe --' — inch <br /> To be commcted to any adjacent driveway pipe Yea ❑ No I� <br /> DRAINAM INLET REQUIRED Yes ❑ No <br /> Total Lmg&- (with proposed) Total Number of St+aam Drain Iimlds <br /> Notes <br /> 3. HEADWALL Yes ® No <br /> 4. PAVED FRONTACrE: PAVED with "Mk.Depth A.C.over "Mm.Depth 3/4"AB. <br /> Mess n* Feet in tenger and Feet in width <br /> MRS <br /> Driveway Encroachment Permit base fee....................:. ...5$S. <br /> � ldMeld inspection <br /> 2vewayw/orw/o pipe_...__ .. _. _ $9S_ ❑Pav®dfiomtagn <br /> ❑ Driveway w/box CnlvaR_. ..___...... _.. _.. .... 00 ❑ <br /> Curb,Gutter,SidnwaIk............ <br /> ........_._$I00:00+0.9878 <br /> CoutrtakCamputcr,cMccess\Application for Pam>ilslDnyeway and Paved Ftuntage Page.2 of 2 Revised&2000 <br />