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1. t aan reran ass resa aut the pcov:swns of um appbDauon,and that the degmiom included infl&application are confect to the best of his/her <br /> imowtvedga and <br /> 2. That he/she is the owner of the respective property,or is qualified to represent 9reovanw,and " <br /> 3.,That he/she will assume full respcasr7>ilily Ex all key for pawed i*wyordamage to property whichmay arise out afthe work desmled above, <br /> or which may arise out of his/her'faitane to do the wmlcprovi led hec+sk and <br /> 4. That in the event any daim of mach liability is made against lbaCondy of San kaom or eery depaartnam$official or empioyce thaeg he shall <br /> ded'end,indemnify and holdiham and etch ofthcad harmless for such chola;and <br /> 5. That worse shall be purred by the applicant and/or any remove ofthe applicant in the Ce:anty Right-of-Way at the abov o indicated aite <br /> wlih a valid San Joaquin County E>rroncbmeat Pamfd;sad <br /> b. That if pemvss ion is granted as requests to do the wade described in acocrdaoce mft aH teonrm,condofimm and teStridicn afthis and any <br /> attached- rndrrde a1 provisions. <br /> Date <br /> FIELD INSPECTOR COADMU rs <br /> »»»» »»»»»»»»»}»»E)MSTDIGCONDMON3«««««««««««««««««««« <br /> L DRAMWAY: NOW , Dist ❑ G M 4el ❑ Amms,&Berme 0 Pavokpoor) ❑ Paved(Good) ❑ <br /> S. SLOPING: Awayfran Pavmnent ❑ Tomardm Pavvmmot Flat ❑ <br /> 3. PREB:. Now Eat-Type <br /> Oiberpipes iande bodaood: Yes ❑ No Approaches ClCres Drain El $ize �] <br /> Anadment to neig dmea Pipe: Yee E] No <br /> 4.HEADWAM- Yea ❑ .No" <br /> S.ASPHALT CONCRETE DIIt3r: Yes ❑ No /(]f <br /> C.BARRffiZS slang Rrgtt&Way v <br /> 1. DUCH Yes ❑ No IfYes:• V Style ❑ 2 Feint ❑ 0d mr ❑ Width Depth <br /> »»>?»»»»»»»»»»»»»»>>PFRbDTREQURMM M<z««««««««««««««««««« <br /> 1.DRIVEWAY: OR ❑ CObIMERCML AAGRtCULTURk ❑ INDUSTRIAL .❑ <br /> PAVED with .hfim Depth A.C.over Y "Mm.Depth 3/4"A.B. <br /> Nates <br /> 2. PIPM Langlh of Pipe R,egaitod:• Ft.and Diameter of Pipe Inch <br /> To be coorbe W to any adjacent driveway pip Yes ❑A1310 <br /> DRAINAGE MET REQUIRED Yea O No <br /> Tell (with proposed) Toftl Naber of S6erae:Draf bdets <br /> Notes <br /> 3. HEADWALL Yes ® No . <br /> 4. PAVED FRONTAqE: PAVED with ".ML Depth A.C.over "Min.Depth 3/4"AL& <br /> bloats ing Fed is length and Feat in wid h <br /> FEES <br /> Driveway Encroachment Paxmit base foe.......................... 00 <br /> Field Inspection <br /> ❑Driveway w/or w/o pipe............. _ .......595.E ❑Paved fimtaga._.....-....._._....__....5100.00+0.46/h <br /> ❑Driveway w/boa Ct>lvert _ ._..__ S13i.00 Cart,Ciuttar,-8idevAir..: 1 0.991ft <br /> �uter,CAAccess\Appliaation for Perm WDgyvway and Paved Frontage Page.2 of 2 R,eviabd W000 <br />