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J.JJJD Lai t"'vera...s+i...a � � - <br /> 1. <br /> I. That he/she has read ah the provisions Of this 8PPfi0x61M said that the descr*dm inciuded intWw application are 0omxt to the best ofhis/her <br /> kwwhvdge;and <br /> 2. That he/she is the owner of the respective property,or is qu"Od to represent a,owns,and <br /> 3..That hdshe will assume fall reBEhamsihMty for alt fiaUiW forpersonal injury damage to property whichnmy wise out ofthe work described above, <br /> or which may arise out ofhiAw figure to do tine work provided herein;aid <br /> 4. That in the event any claim ofsuch Ralik is made agraimt theCormty of Sam]tom ormy. offiK d or empb*m%ec*oC be shall <br /> defend mdemnify and hold t m and each of them harmless for sods cta*and <br /> S. That work shall be peafornsed by the applicant and/or any represrdgtiye of he aWficaast in the County Rigg Way at the above"indicated site <br /> with a valid San.Joaquin County F,ncroachmeot Bemu;and <br /> 6. That if Permission is granted as requested,he ar7m to do ribs wads described inamardance Witlh all <br /> attached shat,included as general a special m p rovistaa>e. ,oond;tims and reshic afthis and say <br /> Sigoataae ofApplicaaot-Tine <br /> Date <br /> FIELD INSPECTOR CONMWM <br /> »»EN8 IMCONDMON3««<««««««««««««««««<<< <br /> L DRIVEWAY- None ❑ put K-.1 ciaavei ❑ Aggrega*Hale ❑ Paved(,w) ❑ Paved(Oood) ❑ <br /> 2-SLOPINQ Awayt'mm Pavamaot ❑ Towanda Paoaament ❑ Mat <br /> 3.PIPES:. None kL Eh -Type <br /> Odmpipm m yes o ❑ Apptosches ❑ Cross Drain ❑ size <br /> Attachment to newthoa's pipe: Yea ❑ No <br /> 4.HEADWALL: Yes ❑ No <br /> S ASPHALT GbNCRETL DIIa►:' Yea ❑ No , <br /> 66.BARRIERS akd #9W t-c&Way <br /> �. DPPCH Yes O .No El IfXes:• vstyle g-21F»nt ❑ Olher ❑ Width <br /> Depth <br /> »>»>»»»»»»»»>;; <br />