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i. t nar nmsae ms reaa err Tire proves Dittos aloe,and that the dWMiptiM ifiChided m flus aplication are comxt to the bast of his/her <br /> knowtwdge;and , <br /> 2. T7rat$elshe is the owner of the respective property,or is qualified to rgxesent the ovvow,and <br /> 3..That he/she will assume fall reapanaJ1jy for aU tiabilily forPawnat injury or damage to properly Wi&may arise out ofthe work described above, <br /> or which may arise out of his/her filum to do the Work provided herein;and <br /> 4. T7mt in the went any claim of such IiabW is made agaiusl*&Con dy of Sm 3Dagiun or any depa oust or mployee thereof;he shall <br /> defend,indemnTy and hold*=and ea&of them harmless fir such claim;and <br /> S. That wore shalt be performed by the apptica*and/or any inpreaent8*M ofthe applicant m the County Right-of--Way at the above indicated site <br /> with a valid San Joaquin Coaaty Encroadima t perndt;and <br /> S. That if pennission is granted as ragiested,he agrees to do the work descri'bed in acombwoe with an terms,oonditioos and restriction of this and any <br /> attached ahem included as geowd or apwW III pmvision& <br /> S ofat-Tate <br /> FIELD INSPEMOR COMMUM <br /> >>>>'>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>>EXVnM4?CONDTITONS«««««««««««««««««««« <br /> L DRItWAY: Now ❑ Dirt ❑ . Antegaft Baas ❑ Paved(lwar) ❑ Paved(Oood) ❑ <br /> 2. SLOPING: Asnyll/inmPavcamei# t� ToiaardsPavama t -❑ Flat <br /> l� ❑ <br /> 3: YlPES:. None E _T� <br /> m Yes ❑ No ,� Approadrea Cores Drain ❑ Size <br /> Aftcbmeut to=W&oea pipe: Yas ❑ No IIQ <br /> 4. JW"WA.L- Yes ❑ No <br /> S. "HALT COpFCRlETIc DM: Yes ❑ Na [� <br /> 6..BARRUM ak"Right c&W&y <br /> �. DIT'CS Yes ❑ No Tfyes:• V Style ❑ 2 Point ❑ Othw ❑ Wid@i <br /> DqA <br /> ?»>»»»»»»»»>"i>»»»»»?»PERDd TREQUMEMENTS<z««««««««««««««««««« <br /> 1.DRIVEWAY: SFR coiv clAl, ❑ A.GR"JLTURE pJNDUSTRL4L .❑ <br /> PAVED With ?- "hfi&DV&A.C.over - ^M.Depth 3/4"A.II. <br /> Notm <br /> 2. PTFE& LarylhofPk-Requkq&• Pt.acid Diaafa0er of Pipe y d, <br /> m <br /> To be ioeoted to any adjsceot driveway pipe Yea ❑ No <br /> DRAINAOIZ INLET REQUIRED Yea ❑ No !� <br /> Tow (wAh PVPised) Toted Number of Sbsrin Drab Lde/s <br /> Notes <br /> 3. HEADWALL Yes Q No Q . <br /> 4. PAVED FRONTAGE: PAVED with <br /> hf L Depth AC.over "Mia Depth3/4"A.B. <br /> Mmming Fed m to ft&and Feet in width <br /> Driveway Encroadrment Permit base fee......................... <br /> �;itS nc✓ �� <br /> Field <br /> Driveway W/or W/o pip'..-...--- <br /> El Ddvewa w/box ElPavedfinats$e __ _ __ 510000+0.46fS <br /> Y C�ilvert._.._._ _...._ 3.00 ❑Crufi,Gutter,Sidewalk.. _.....5100.00+0.9&,ft <br /> CorndMWOsnputer,c. ccese\Appliaation for Pem>itsllkipeway and Paved Fron sgp Page.2 of 2 <br /> Revised 8/2000 <br /> V, <br />