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111M. rrJ LL%1A 1%x JULAUAWLWAYA. �.sisaa aa•...,�a. <br /> 1. Thd ha/s@ehas read all the provisions of this appficsfiM and that the desc riplion inc tided iaggs,applications ata comeet to the best of his/her ' <br /> kmwlwdge;and <br /> 2. That he/she is the owner ofthe respective property,or is qualified to reprrsa t ibo owner;and <br /> 3. That helshe will assume fall responalkility€N alt lids&Y fwp rsonai irgray Ordamage to property whichm"seise out of&o work desc ril"d above, <br /> or which may arise out ofWs&w failure to do the workparaidedhanin;and <br /> 4. Thst inthe event any claim of such liability ismade against th Covndy of&0 IDaajeun or any daparbm*ogicial or employee tbereog he shall <br /> ded2asd,indanz*and hold&=and each of them harmless for such claim;and <br /> S. That work shall be performed by the applicant and/or say representative of the applicant in the County Rigid-of-Way at the above k&cated site <br /> whh a valid Saa Joaquin County Encroachment Pe,,R;and <br /> b. That if permission is grated as regisesfed,lee agrees to do fhe wade doscdbed in awmbtnee vyi&alt te®ss,eaodit,=and mWicfim of this and ate+ <br /> mwhod <br /> 43 <br /> SrgnatateofAppliCxTiite Dat <br /> FLELD INSPECTOR C OMMW l`s <br /> »»»»»»»»»»»»»»»»»»»W(IS'iOnCONDiTiONS«««««««««««««««««««« <br /> L DM*RWAY: Nene ❑ D&t ❑ } ciravnl ❑ Aggregate mats ❑ P9_%)o_) ❑ Pave kOood) i <br /> 2.SLOPING: Awayfi+ms Paveanreot Towards Pavemaot y❑ Fiat ❑ <br /> 3: PIPEt3:. Now ❑ Earofiog-Type <br /> O&W Pipes in nOghborhood: Yea ❑ No Approaches ❑ Crew Drain ❑ Sire <br /> Attachment tonaglabar% Yea ❑ No <br /> C MADWALL: Yes ❑ No" <br /> S.AMIULT OONCREI"L DIKE:; Yes ❑ No <br /> 6..11ARRUM a k"Rigbto&Way <br /> 1. DUGS Yes 446--'No ❑ IfYes:• V Style 2 Point ❑ Other ❑ VrW& Depth <br /> »»»»»»»»»»»»»>> >.>> <br /> L DRIVEWAY: SFR {OMMERCML Q A:ORtCIILTEIR$ ❑ INDUSTRIAL ❑ <br /> PAVED with 2- "ldm.Depth A.C.over "Min.Depth 3/4"A.B. <br /> Nates <br /> Z. PIPE& Lasgih of Pups Required:' Ft.and Diau6ebw of Pipe inch <br /> To be connected m any adjacent driveway pipe Yes ❑ No <br /> DRAINA13E INLET REQUIRED Yes ❑ No <br /> Tow Length: (with proposed) Tata{Nwober edSOtem Drain Inlets <br /> Notes <br /> 3. HEADWALL Yes 0 No <br /> L PAVED FRONTAGE: PAVED with "Wm.Depth A.C.over "Mm.Depth.3/4"AB. <br /> Measuring Feet in ten ih and Feat in width <br /> FEES <br /> Driveway EncroachmentPermit base foe_._.................. <br /> Freldhpecfion <br /> AiDWaway w/or w/o pipe._....... .._._ _ 59 ❑Favell froofsga _. _._. _ .__ 510000+0.46/ft <br /> El Driveway w/box(MveR._. ❑Chub,Clatter,Sidewalk.. . S10D:D0+0.99M <br /> Ccur ,derlComputer,c.McceselAppliaatior fir Permftffkiy y and Paved Fri AW Page.2 of 2 Raviwd.=000 <br /> e� <br /> \, <br />