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THE AI'PLIUAN'f IMK EHX UZKKM'MS: <br /> 1. That he/she hes read ail the provisions of this MffimtiM and that the description included inthis application are coarct to the bast of his/her <br /> kDowhvdge;end <br /> 2. That he/she isthe owner of the respective property,or is gwdifiedto represent doowreq,and <br /> 3. Thai he/she will assume full responsihility for air hab ky forpaaomi urmy or damage to property whichmay arise out ofthe wodc desca4bed above, <br /> or which may arise out of hk&w failure to do the work provided here and <br /> 4. That im the evert any claim cfmmh liabihhy As made against OCounty of San ksgi m orally dam,official or employee thaeot he shall <br /> defend,indermify and hold*=and each of them hamvless for such clan;and <br /> S. That work shall be performed by the applicant and(or any representative of the applicant in the County Rigint of_Way at the above indicated site <br /> with a valid San Joaquin County Encroachment permit;and <br /> b. That if permission is granted as rnguestod,be agrees to do the work descried lin accordance with all tams,omditims and restriction ofthis and any <br /> �i��k included as gaurai« III proowsions. <br /> Date <br /> cf�lpp�iCmt Tice <br /> FIELD INSPECTOR CONMI;NTS <br /> L DRftWAY: Nome1 <br /> ❑ Uict � Cnravd ❑ . Aute Base. ❑ Paved(poor) ❑ Paved(Good) ❑ <br /> 2. SLOPING: Amy from Pavameot ❑ Towards Pavumaot ❑ Flat ❑ <br /> 3. PIPES:. None �Ic_ E _Type <br /> Other pipes m neiAbodnood: Yes ❑ No Approaches ❑ Cross Drain ❑ Size <br /> Atta�to neigWee lam: Yes ❑ No <br /> 4 HEADWALL: Yes ❑ No Xr�SI <br /> S ASPHALT CONCRETE DIKE.- Yes ❑ No <br /> 6_BARRURS along Rq t-c� ay�1' A reH omt l/ ©1U &me S1.DE <br /> 7. DTl CS Yes .No ❑ IfYes:• V Style ❑ 2 Poirot ❑ Other. ❑ W-,M Depth <br /> PERMITREQUIREMENTS<z«««««««««««««««z«««< <br /> 1.DRIVEWAY: SFR COMMERCIAL. ❑ AC4RfCULTLTn ❑ INDUSTRIAL .❑ <br /> PAVED with i "Wm Depth A.C.over ")Am Depth 3/4"AIK <br /> Notes <br /> 2. PIPE& Lena*of Pipe Rawk9d:• FL and Diana r of Pipe Lich <br /> To be connected to any adjacart driveway pipe Yea ❑ No <br /> DRAINAGE INLET REQUIRED Yea ❑ No �I/ <br /> T«aa (wish proposed) Tore/[NNmnber of Steals Drak Islets <br /> Notes <br /> 3. HFADWALL Yes ® No <br /> 4. PAVED FRONTAGE: PAVED with 'Wm.Depth,A.C.over "llsim Depth 31V A.B. <br /> Mg Fast in lath and Feet in width <br /> FEES <br /> Driveway Enanac hmm t Permit base fee...........................585. <br /> old Inspection <br /> tla <br /> veway w/or w/o pipe.......... :. _ S95.4Q ❑Paved finatage _.___ _ 5100.00+0.46/& <br /> ❑Driveway w/box Culvert._.........,............_ ... ....__. ❑Gut,(nutter,SMm.J c_....._...............$100.00+0.98/B <br /> CountakCompi ter,c:lAccew\Applioat m for Penia >d eway and Pavel Frontage Pap.2 of 2 <br /> Revised 8/2000 <br /> i <br />