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't til';ArrjUj%-j ,%a n.c.aar4m a a.r.aA�,... <br /> 1. That he/she hiss reed aH the provisions of oris applicatiom and that the deoariptim included in flu`s application are monad to the best of his/her <br /> lmowlvrdge5 and <br /> 2. Thrt he/she is the owner of the respective property,or is qualified to represent the owmr,and <br /> 3. That he/she will assume tvu responsibility Ear all liabifity Eur personal injury or damage to property YAWA may arise out of the wodc deWfibed above, <br /> or which may arise out of his/her Were to do the work provided becarr;and <br /> 4. TM in the eved any claim of arch 6abr'M'y it made agaimel the County of San Joa*m or any departued,dual or employee thereof he shall <br /> defend,indemnity and hold them and each of them bas o>ieas far such edam amd <br /> 3. That work Shall be pedormed by the applicant and/or any reprnamtative of the applicsut in the County Right-of-Way at the above indicated site <br /> with a valid San Joaquin County Enavechina t permit;and <br /> 6. Tbd if permission is graded as requested,he agrees to do the wads described in a000r dance with all tamm conditions and teatidioa of this and any <br /> attached as III <br /> SigneWeofApplicaa6Titte Date <br /> FIELD INSPECTOR COBPPf3 <br /> »»>>>>> »»»»»»»»»»»>>E)(ISTU40 COMMONS«««««««««««««««««««« <br /> t <br /> L DRIVEWAY: Name ❑ Dirt Gravel ❑ AM"Me ase ❑ Paved(poor) ❑ Pava(0ood) ❑ <br /> 2.SLOPING: Away fivan Pavacnad ❑ Towards Pavaueut ❑ Flat r� <br /> 3.PIM: Now ic Foisting-Type <br /> Other pipes in neighborhood: Yea ❑ No Approwha ❑ Crus Drain ❑ Si. <br /> Attachment to neW&oes pipe: Yes ❑ No <br /> L HEADWALL: Ya ❑ No <br /> S.ASPHALT CONCRETE DOW Yes ❑ No <br /> & BARRIERS akxW Rigbt-c&Way <br /> 9. DPPCH Yea ❑ No fi& IfYes: V Styb ❑ 2 Point ❑ Odw ❑ VrmM Depth <br /> »»»»>>>>> »»»»»»»»»»PERMTI'REQUMEME iT6«««««««««««««««««««« <br /> L DRIVEWAY: SFR Z yyCOMMUCLAL ❑ A RkAXTURIE ❑ INDUMVIAL ❑ <br /> PAVED with C-- "llin.Depth A.G over "Min.Depbr 3/4"A.B <br /> Notes ex)Sno)" ( 1Cctrtie <br /> 2. PIPE& LA%*QtPip6 R-rued: Ft.amd Diauapler of Pipe Inch <br /> To be oomnected to say adjaoeat driveevoay pipe Yea ❑ No <br /> DRAWAM INLET REQUIRED Yea ❑ No 12ri <br /> Taus!Length: (with propwed) Total N=Wkr of Ston Dani l idef: <br /> Noes <br /> 3. HEADWALL Yea Q No <br /> 4 PAVED FRONTAGE: PAVED with "Mm.Depth A.C.over "T is Depth 3/4"AB. <br /> Measuring Fed in teeg$and Fed io width <br /> FEES <br /> Driveway Paav+chmeot Pam it base fee............. ...S85. <br /> FreldUmpection <br /> &,-}runway W/or W/o pipe.......... _ — ❑Paved Srnar+ger__ __.__ __---S100 00+0.46Hi <br /> ❑Drivewayw/box Calvert_. ___._ ..._.___.._...__.S ss.00 ❑Curb,Or#er,Sidavallr..._ _._._....SL00.00+0.98/ft <br /> Ccumtakcam ter;c:VWOcss Appiioaticn for Permwodyeway and Paved Frontage Page.2 of 2 RAvised 82000 <br /> ' i <br />