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I. inm nwuw sus nm au use provrstans m mss appnr.xuo4 and that ffie clew ption included k0m mftatiom ane comxtto the bast of Mulles <br /> Ionowhvdgq and <br /> 2. That he/she is the owner of the respective property,or is gm"ed to rgxtrsemt the ovm04 and , <br /> 3..That he/she will assume full respaoliity ihr alt may Forpersonal injuryordacump so loPaty which may arise out ofthe wo&described above, <br /> or which MAY arise out offib&. w failure to do the wmkpmvidedherek and <br /> 4. That in the eval any claim o(sueh liability is made against A*Cotudy of Sm]bagiiun of any depaxtomak official a amPloYce thawg ha shall <br /> defend,indemnify and holdli m and each ofthem hemden for such grin;and <br /> S. That work shall be pedemwd by the applicant and/or any repromi tine o(lb,apphC=t in the County gi*-of-way at the above indicated alts <br /> with a valid San Joaquin Comely Fncx+oacbma t and <br /> 6. That if penmiasion is granted as reclrrested,he agrees to do the wed;&escdbed in scomhme wi&all teas,conditions and rrstriatian ofWis and any <br /> attached included as general or We W Ill provision, <br /> - � ©5--� o <br /> t-7 i Date <br /> FIELD IpISPEG�Oi;c c�olm�avTe . <br /> EMSTIMCONDMONS«««««««««««««««««««« <br /> L DRI VEWAY: Now ❑ Dict Gravel ❑ Aggregate Base ❑ Paved(pooe) ❑ Paved(Good) ❑ <br /> 2. SLOPING: AwayEom Pavameot ❑ Towards Pavem mt -El Plat <br /> 3: PIPES: Now Elg-Type ��f�r I C6 44 C.9-ET� <br /> OtbarpiPesrn Yea No ❑ Approaches Cross Drain ❑ Size <br /> Attadma°°t to naghbor"s pq,o: Yes No El <br /> 4.HEADWALL: Yes ❑ No, at,/. <br /> S.ASP)#ALT CONCRM DM.- Yes ❑ Na <br /> G..BARR1 MS along itigbwo,May <br /> 7. DPPCH Yes ldl No ❑ IfYes:• V Style 2 Point ❑ 0d., ❑ Wiidth DeA <br /> PEdRM1TREQUIRE199 TS<z«««««««««««««««z«««< <br /> L DRl[P&VIFAY: smote MERGIAI. ❑ AC#RfCULTVM ❑ INDUSTRIAL .❑ <br /> PAVED with Z—,.R W,Dapth AC.over 4 "ilio.Dv&3/4"A.S. <br /> Nates <br /> L PIPE& L4%*of Pipe Regnirv&. FL and Diameter of pipe inch <br /> To be connected to askya4acert driivewmy pk Yes ❑ No (o <br /> DRAINAGE INLET REQUIRED Yea ❑ No <br /> Tot4I I'eOgth- (with Proposed) Total Nuasber of Sbogm Drak Itsfds <br /> Notes <br /> 3. HEADWALL Yes Q No <br /> 4 PAVED FRONTAGE: PAVEDwith ".tom,DeA A.C.ovw "hfim Dep8s3/4"AS. <br /> Feet in length and Feet in width - <br /> Driveway Fna-whn3e t Peanut base fee...........................585 FEW <br /> od <br /> FlE'1i7rrv�way� <br /> w/or w/o pip s.......... <br /> 61;5., <br /> ❑Driveway w/box L5xlvart„._ __...._ ❑Pave/ --�.-�-�------ _ Si00.00+0.46/E <br /> 55.00 ❑Ctub,Clatter,Sidewailc.. . .. ....._. 5100.00+0.98/S <br /> Calako ;ompute"C-*V=eaalApplf m ion for PemAslDriyesway and Paved Fron4p Page.2 of 2 <br /> Revised 82000 <br />