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I. That he/she Bas sena an une prov>shom ur user aWPzK2uxju�can mar me aescnpex s■n"wc.uw,......o. u.A.......... . .. .. .___ _ ._ <br /> kmwbvdge'and <br /> 2. That hdsho is the owner ofdw regm ive pnopaty,a is quahf"hedto r &eownea:,and <br /> 3. That h e✓she will assume full responsi iTty hr all HAURY forpmonai injury ordamage to property whkhmay wise out ofthe work desmibed above, <br /> or whioh may arise out of hb&w failure to do'dhe wank p wktai heroin;and <br /> 4. That m the eveat any claim of such lidWity is made agaist iheCoumty of Saab Yoaqim or any department officW or ar&yw tlhare4 he shall <br /> ddmA mdmnify and holdthem and each of them hmrmiesa for such claim;and <br /> S. That work shall be performed by the appiic as t and/or any representative of the applicant inthe County RigM of-Way at the above indicated site <br /> with a valid Saa Joaqum County Fnanadmhest Pe wd;and <br /> b. That if permission.is graatad as requested,he agrees to do the wort doscar'bed iaanonrdanoe wide all terms,condo um and rnaaictiam afdne and any <br /> attached dwK included as general or special M provisions. <br /> • ` � -���T��,r�-/./moo �--�_�-� <br /> 8igmtore afRpplic:eami4Ma Date <br /> FMLD I14SPEGTOR COBOMUM <br /> »»»»»»»»»»»»»»»»»»»»E ST1140CMI)Mt7N8««««««««««««««<«««««< <br /> L DM'i WAY: Nano ❑ Dnt } Oravai ❑ Aggre eBase ❑ Paved(poar) ❑ Paved(Qood) ❑ <br /> 2.SLOPINQ Awpayyf m Pa..t Towanda Pa—cit ❑ Flat '❑ <br /> 3:IPiPBB:. Now � EfWag-Type <br /> Otherpipesiaasigbtharhood Yes ❑ No App omiches CromDrain ❑ Size <br /> Attsd:mact io neigLbuc'a pipe: Yes ❑ No <br /> 4.l3FAl)WALd,: Yes ❑ No <br /> ASPHALT CtDPI DIIi15:a Yes EQ No <br /> 6L.BARREMS ak"Right-o&W** <br /> 1. DPPCS Yes ❑ No Ifyea:• v Style ❑ 2 P6int ❑ Odwr ❑ W ix1h Depth <br /> » ««««« <br /> L DRIVEWAY: OR COMMERCIAL ❑ A ,TURP ❑ INDUSTRIAL, ❑ <br /> PAVED with. "Mp.Depth A.G over _"Mm.Depl h 3/4"A.& <br /> Nates <br /> 2. PIPE& U%6 of Pipe Req iced:' Ft and Diaageter of Pi" <br /> To beoaoneded to any adja scut*Wm"Pipe Yea cn� NF, tgi� <br /> DRAM INLETREQUIRED Yea ❑ No <br /> Total Length (with proposed) Total N�irt of t :Durair Theist <br /> Nom <br /> 3. EMWWALL Yea 0 No <br /> 44. ?AV=MONTAGE: PAVM with "Mm Dap*AC.over "Wm Depth3/4"AR <br /> Masaumg Feet in length and Feet in wift <br /> ' IlB.P.i3 <br /> Driveway FihmaacLmeatt Permit base See.........:......... <br /> RSL_ :...�S85.gy' <br /> nriveway w/or w/o piper..».» » _ _» 595_(!0 ❑Paved&mrtaga _» _ __ $10000+0.46/& <br /> F1 5.00 ElCurb,(Maar,SidewaDr.»:.._...:.»......»Si00:00 <br /> Cattr'10Camputa;c:44cce08\, lioation for Pcrmdg sway and Paved F..tags Page.2 of 2 Revised W2000, <br /> `y1 � <br />