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tt►�AYrJt�a.��� nn,n��x i.�rcttrt�a: <br /> 1. That he/she hes read all the provisions of this Wfication,and mat the desa*dm i xhded mthis application ate correct to the bast of his/her <br /> knowledge;and . <br /> 2. That he/she is the owner of the respective property,or is qualified to hereat the owner;and <br /> 3. That he/she will assume full respansr'h+ility for all fitmrTdy far personal injury ordamage to property which may arise out a£me work described above, <br /> or which may arise out ofhis&w failure to do the work provided herein;and <br /> 4. That in the event any claim of such liability is made against theCoady of San Aoagiun or any depertnsei,official or employee thereof;be shall <br /> defend,indemnify and hoaithem and each of man harmless for such da*and <br /> 5. That work shall be performed by the applicant and/or nary rte of the applicant in the Conusty Right-of-way at the above indicated site <br /> with a valid San Joaquin County Encroadvaent Pen nW,and - <br /> 6. That if pemrission is granted as requested,he agrees to do the wadc desrn'bed in accordance with all terata,conditions and restriction ofthis and <br /> any <br /> attached sheet inchded as general or a ecial III provisiotta <br /> t�,. O rem <br /> SigmtnneofAppfican&-Tito Date <br /> FIELD INSPECTOR COACM110M <br /> »»»»»»»»»»»»»»»»»>t»»E)aST NO CONDITIONS«««««««««««««««««««« <br /> L DRATWAY: Naos ❑ Dirt ❑ (fraud AWegate Base ❑ Pav*poor) ❑ Pav*Good) ❑ <br /> L SLOPING: AwaySnm Pavement ❑ Towards Pavemad Flat <br /> 3. PIPES: Now ❑ Existing-Type <br /> Other P in Yes ❑ No Approaches ❑ Ctnas Drain El S. <br /> Attachment to naigWw%pipe: Yes ❑ No <br /> 4. HEADWALL: Yes ❑ No . <br /> ASPHALT CONCRETE DIICL: Yes ❑ No <br /> 6..BARRIERS akagRight�W <br /> 7. WPM Yes WNo ❑ IfYes: V Style 9-2Point ❑ Owher ❑ Width Z Depth <br /> »>»>»»»»»»»»»»»»»»»»»PERMIT REQU REMENTS«««««««««««««««««««« <br /> i_DRIVEWAY: SFR J4 COMMERCIAL ❑ AC3RJUMTURE ❑ INDUSTRIAL ❑ <br /> PAVED with - "Mm.Depth A.C.over / "Min.Depth 3/4"A.B. <br /> Notes <br /> L PIPE& Length of Pipe R,equi v& Ft.and DiamAer of Pipe Inch <br /> To be connected to any adjacent driveway pipe Yea ❑.No <br /> DRAINAGE INIET REQUIRED Yes ❑ No <br /> Total> (wim Proposed? Total Nwnher of Stumm Drain Idets <br /> Nates <br /> 3. HEADWALL Yes ® No . <br /> 4. PAVED FRONTAGE: PAVED with "Mm.Depth AC.over "Mia Depth 3/4"A.B. <br /> Ming Feet in length and Feet in width <br /> FEES <br /> Driveway Faaoacbment Permit base free................ ..... ...585. <br /> Fjold Inspection <br /> Driveway w/or w/o pipe...... .. ._. . _.. ..595.00 ❑Paved fi oactge_ .___ _ ..__ S10Q00+0.46/& <br /> ❑Driveway w/box Calvert._.......................__..._.. -goo ❑Curb,Outter;Sidewalk.......................5100.00+0.98M <br /> Counter\Computer,c:)AccesslAppliostion for Peen WDriyeway and Paved Frontage Page.2 of 2 Revised 8/2000 <br /> `1 <br /> . :1 <br />