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1. That <br /> he/site all the prcivisione of this appy and that the desc rip im incin ded inthis application are correct to the best of his/her <br /> Sq and <br /> 2. That he/she is the owner of the respective pr%etiy,or is qualified to represeut the owned and <br /> 3..That he/she will assume fall responsibility for all fiabxTdy f¢,p iffliuryordamage to PCOPOItY W"May arise out afthe wodc d above, <br /> or ovhich aray arise oat of his/her failure to do the work pcovided haeio;and <br /> 4. That in the event any claim of ow i liability is made again j%&Coarrty of San 3oagant or SnY fterhmat offidd or employee 9wreot he sball <br /> defend,indemnify and hold&=and each afsham harmkas for such clahq and <br /> S. That work shall be pedomred by the applicant and/or Say rape ye of the applicant in the Conaaty Right-of-way at the above mdieatod site <br /> with a valid San Joaquin County Fncroadment p and <br /> 6. That if permission is granted as requested,tie agxea s to do the wodc described in acocrdanee with an terms,conditions and restriction and any <br /> attached mat,' as general bar R)ecial Ili PWVjdOM <br /> . aG <br /> S ofAppHc@m6-TM& <br /> Date <br /> FIELD INSPECTOR COMMMM <br /> >>EXM TI NOCONDrnONS«««««««««««««««««««« <br /> L DRftWAY: Now ❑ Dict } Gravel <br /> (�tti Aggregate Base ❑ 1'+ord(Poa') ❑ Paved(Good) ❑ <br /> S. SLOPING Away&ma Pavement <br /> Tovaarda Pavmneet ❑ Flat ❑ <br /> 3. PH%S:. Now RV Eaistigg-Type <br /> Othxpq>en m Yes ❑ No Approechea Q CrossDrain ❑ size <br /> Attachment to neighbors Yes ❑ No <br /> 4. HEADWALL: Yes ❑ No <br /> S. ,ASPSALT CONCRLrrZ DffM- es ❑ No <br /> G.BARRIERS akWWA ght-o&Way ' <br /> t DITCH Yes ❑ No If Yes: V Style ❑ 2 Pbint ❑ Other, ❑ Depth <br /> W <br /> '»»?�>PERLITTIBQUMEIdENTS««««««««««««««««z«««< <br /> 1.D1tIV .WAY. SFR COMMERCIAL. AGRkMTUaa IND ❑ <br /> over <br /> PAVED with Z-- .. �A.C. 1� <br /> " Depdi 3/4"A.B. <br /> NotRa <br /> 2. PEM& I elk of Ft.sad Diameter of Pipe inch <br /> To be connected to any adjaoer4 driveway Pp Yes ❑.No , -- <br /> DRAdNA0E MUT REQUMED Yea No <br /> Ar— <br /> Tow 1'0O* (WI&Pmpenal) ToW Nwabw of Stagy Drsk IMela <br /> Nara <br /> 3. HEADWALL Yee Q No <br /> 4. PAVED FRONTAGE: PAVED with "Dam.Depth A.C.over "Mm.Depth 3/4"A.B. <br /> I ft" Feet in leng&and Feet is width – <br /> FM <br /> Driveway Fumadment Permit base flee................_........ <br /> eld Impaction <br /> sway W/or W/o pips.. ..... .. _ _ <br /> ❑DdvowaY w/box ❑Paved fi anlage <br /> Cutve�t._._._ ..... .__ ._... .. Si.00 ❑Cork Datta',Sid.71L.....----$100.00+0.98/ft <br /> CauntakComputer,o:lAooaslApplication for Pem WDrivsway and Paved Frontage Page.2 of 2 <br /> Revised 8/2000 <br /> ,t <br /> i <br />