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1. That he/ste bas read all the provkk=of this appficafioq and that dwdesmipticniicksded m this applic:ntion are cone to the best of his/her <br /> kmwhwdge;Md <br /> 2. That he/she is the owner of the respective pfopedy,or is qualified to rq x+eamt the ownwand <br /> 3. That he/she will assume fall c+gpaaafity for all iAi&y for personal injury or damage:to paopeaty wbirh may arise out oftbe work desmbal above, <br /> or which nsay afire out of his/her Eaifnne to do the workpmvided heaein;and <br /> 4. That in the event any daim of such liability is made agxieat theCoamly of San aoagim or MY depw ,official Of employee VMfecf,he shall <br /> defend,indemnify and hold 6m and each ofthem hamzlew for such claim;and <br /> S. That work shall be peafamed by the applicant and/or any represecishft of the appficant in the Coattdy Right-of-Way at the above indicated site <br /> vd&a valid San Joaquin Coudy Fnamdv neat Pemai>;and <br /> b. That if pemission is gmabed as regiiestal,he agrees to do the work descaa'bed in accacdaace with all temps,oondidow and teshic bon of this and any <br /> dwhed*wet,included as general ar special III provkioos. <br /> SignaUmofApp}icaet-Title Date <br /> FIELD INSPECTOR C011TS <br /> »»»»»»»»»»»»»»»»>}»>>EXIBTflgGCdN=ON3««+c«««««««««««<d«««««< <br /> L Mti AY: Now ❑ Vitt ❑ Gravel AgpgpteBase ❑ Paved(pow) ❑ Paved(Good) ❑ <br /> 2. SLOPING: Awayfwm Pavameof ❑ Towaads Pavawaot -p Flat <br /> 3: P)EPES:. <br /> Now ❑ Ea sft-Type Q "^' ahW <br /> Odwrpipes ia=W*odwod: Yes ❑ No Appaowhw E-1 Crm Drain ❑ Size <br /> Alladmuttomighbah Yes ❑ No <br /> 4.HEADWAId.,: Yes ❑ No . <br /> S.ASPHALT CONCRETE BUM- Yes ❑ Na <br /> 6..BARRIERS #ggRi*,o&Way <br /> 9. DXMW Yes No ❑ IfYea• V Style 2 Point ❑ Other ❑ WiWa Dept <br /> »»»»»»»»»»»»»»»»»PERIff MQUEREMOM<z««««««««««««««««««<< <br /> 1.DRME.WAY: SFRCObIT�ERCIAL ❑ T LIRE ❑ INDUSTRIAL ❑ <br /> PAVED with "Mm.Depth AC,over �Ism DepHa 3!4"AB <br /> Notes <br /> 2. PUT& 11-y*of Pipe Regaiarod:- Ft.and Dianie6er of Pipe Iaeh <br /> To be eoanected to any adjaceact rkiveway pike Yee ❑.Hoo <br /> DRA IX&M INIETREQUMED Yes ❑ No <br /> Total Le% (M&pavpom* Total Number of S6ccu Drabs huleks <br /> Notes <br /> 3. HEADWALL Yes n No <br /> 4 PAVED FRONTAGE: PAVED with _�"Dfm.Depth A.C,over "Mn.Dq*3W AR <br /> Mesauring Feet in langur aad Feet in width <br /> FEES <br /> Driveway Faaoadmnut Peanoit base fm........................... <br /> Inspection <br /> Driveway w/or w/o pipe......... _. _ $95. ❑Paved finangcga _ _ _ _ 510000+0.4678 ' <br /> ❑Driveway w/bos Calvet ._._ . . . _. 5.00 ❑Cuab,Guitar.Sidewalle..: _5100.00+0.9878 <br /> CeunteslComputec;c:V=e=\Applioation for PeamilalDgyaway and Paved Fmntage Page.2 of 2 Revised 872000. <br /> 5 <br />