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1. That he/she has read all the provisiongofthisappliedionj amd that the desa46oa irk iatbis application are convdto the best ofhis/her <br /> Imovdmige;and <br /> 2. That he/she is the owner of the respective property,or is qu Efied to represent dw ,ownw,and <br /> 3. That he/she will assume full vespWalffity far all fiA&Y forp=021*iucy or damage to property whichmay arise out ofthe work described above, <br /> or which may arise oat of Na&w failono to do the work Provided Herein;and <br /> 4. That in the evert any claim of such liablM.y is made apismi the County of Sea aoarlsra or my depart sent,offiew or employee thereof he shall <br /> defend,indemnify and hold&=and each of*am harmless far such dun;and <br /> S. That wase shall be performed by the applicarg and/(r say representatift ofthe applicant im the Coutrty Right-of-Way at the above indicated site <br /> with a valid San Joaquin County Fmroachmamt Permit;and <br /> 6. That if permission is granted as requested,he agrees to do the mark desaubed is acaerdanoe with all teams,condition and restcidion cf this and any <br /> attached duct included as genu t sgseial) �mo <br /> 3ign�trc ofTitle .Data <br /> FIELD INSPECTOR COADM N'TS <br /> »»»»»»»»»»»»»»»»»>4»»E)MSIM G CONDMONS««r«««««««««««««««««< <br /> L DRiWAY: Ncoe ❑ mt Cl C$avd � Aggregate Base, ❑ .Paved(paa') ❑ Paved(Good) ❑ <br /> 2. SLOPINGe Away$nm Pavement Towaeds Pavement ❑ FJat ❑ <br /> 3. PIPES:. Now ❑ Eais ft-Type <br /> Otbwpipmmnd&bodm& Yes No Approaches ❑ Crow Dram ❑ Size <br /> AtYadnmart ioneighbor's pipe: Yes ❑ No <br /> 4. HEADWALh: Yes ❑ No' . <br /> S.ASM ULT CGIMRETE DIIC6: Yes ❑ No <br /> f~.SARR)ERSS along kigbt-orf,-�W{ay <br /> 7. D= Yes o ❑ Ifyat:• vswe Faint ❑ Od w ❑ Mid& DqA <br /> »»»»»»PERMITREQUIItElSENTS«««««««««««««««««««« <br /> 1.D]RIVEVKAY: SFR CObIL4ERCIAI. ❑ AGRtCULTURk ❑ INDUSTRIAL ❑ <br /> PAVED with 2 "tram.DW&A.C.over' "MM DqA 3/4"A.B. <br /> Notes <br /> 2. PUMS% ofPipe Regaicect' Ft.$Ad Diem w of Pipe Inoh <br /> To be coonecoed to any adjacent driveway pipe Yes ❑,N <br /> DRAWAGE RUM REQUIRED Yes ❑ No Ir— <br /> Tow (WA Proposed) Total N=Wkr of Sb w=.Dr ak Inieft <br /> Nates <br /> 3. HFADWALL Yes No <br /> 4. PAYED FRONTAgE: PAVED with hfiL DepOk A.Q over "hfia.Depth 3/4"A.B. <br /> bieastu'ing Pastia sad Feet is width <br /> PFZS <br /> Driveway Faaoac>m emt Permit base he.............._.... <br /> .,�01 <br /> , j Id Inspection <br /> t61 ,waywl or w/o pips......._ _ _ S100 40+0.461& <br /> ❑Paved 13mataga.._....__..._r..__.... <br /> ❑Drivewayw/6ox Calvert._ _ —._ .. ._....— 155.00 ❑Curb,Com,Sidewak......................5100.00+0.98/ft <br /> Counter\Computer,c: c:emlAppliaation for PenmitslDriyeway and Paved Frontage Page.2.of 2 Revised 812000 <br />