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1. That he/shehas read all the provisions ofthis VOCUtiOni and that the dwm*fim included iia tW anfficatiou are cowed to the best ofh&lw <br /> hnowiwdge;and .. <br /> 2, That he/she is thio owner ofdw respediVe property,or is quahSiedt+o represent theowrw and <br /> 3. That he/she will assume fall responsibility Esau batty for personal injury or damage to property wlnrhmaY arise art ofthe work deacaibed above, <br /> or whichmay arise out of Ws&w farare to do the work proviided herein;and <br /> 4. That in the event any claim of auch liability is made against ftCovntnt,y of San loagim or any depmtmrofficial or employee thaw shall <br /> defend,indemnify and holdO m sad each of them barmlesa for ands chin;and <br /> s, That work shall be perfmned by the applicant and/or any Mprwentafiw of fie applicant in the Cowtty Right-of-Way at the above indicated site <br /> with a valid San Joaquin Coady FAcc oad out Pasant;and <br /> 6. That if pwmissi(a is granted as re*wated,he arm to do the work described in a000r+daaoe with an turns,conditions and restriction ofthis and any, <br /> atbrbed sheet,included as general ar special Ill onw <br /> afApp}uxat- ills Date <br /> FUMDINSPECTORCONMIRM <br /> >»»»»»»»»»»»»»�»»»>�»»EXiBTRgOCONDMOrNS««+c«««««««««««<«««««« <br /> L DRIVEWAY: Nom ❑ Dirt ❑ Oravd ❑ AM*SateBase ❑ Paved(poor) ❑ Paved(Oood) <br /> 2. SF"INGe Awayfi ca Pavement Towards Pavawe t ❑ Fier ❑ <br /> 3: PJPW Naos g-Type <br /> Other pipes ianvioibodmd: Yea ❑ No Approadwe ❑ Cross Dram ❑ Sim 1�•J <br /> Attadmenttwno~ Yes ❑ No <br /> L IMDWALL- Yea ❑ No' . <br /> S.ASPHALT OONCR=D=: Yes ❑ No, <br /> 6..BARRIERS along Right-a&Way <br /> '/. Dirm Yes ❑ No IfYew. V Style ❑ 2 Phut ❑ Ofber ❑ W-W& Dep& <br /> PgRLUTREQUIREMENTS<z««««««««««««««««««« <br /> 1.DIM..WAY: SFR AL COMMMML ❑ AGRICULTUIRJE ❑ INDUSTRIAL ❑ <br /> PAVED with "Mm.Depth AG over "Mm Dept 3/4"A B <br /> Nates <br /> 1. PIlBlie Law%of Pipe Regaim&- Pt.and Dian ktlw of Pigs inch <br /> To be 000necwd to say*V&oeat driveway pipe Yes ❑ No <br /> DRAWAOE D!iI.ET REQUIRED Yes ❑ No <br /> TaW IA*% (with proposed) Tobe/Nwaber of S/am:Dada WOfa <br /> Notes <br /> 3. HEADWALL Yee Mn No <br /> 4. PAVED FRONTACFE: PAVED with "lvlio Depth AG over "Mss Dept 3/4"AA <br /> Meaauyag Feet in lend and Feet is width <br /> FEES <br /> Driveway Encroachment Permit base fee............._._..... ... <br /> Inspei�ion <br /> ewayw/arW/o pipa.._... _ $9 . ❑Pavedfrattit:ga..—.__..... »—....-....$100.00+0.46d <br /> ❑Driveway w/bos Cahwt...._......._.._...._....._............_..$155.00 ❑Carie,Oumw,Sidewalk..: __. Si00.00+0.9&2 <br /> C.auntetWomputer,c:lAcceas\Applaetion for Pem ds\Dnv way and Paved Frantage Page.2 af 2 Revised W000 <br /> i � <br />