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j, That <br /> .,],7y2/�6,},8�1.g181Ct all the PfOV181� Oq of�1HS Bpp and 1}Y the dC8f Olt IDC117d9d In 8pp11CShOIk am correct t0 X116 b@SC of his/her <br /> kwwhvdge,and r <br /> 2. Tbat he/she is the owner of the respective propedX,o is quat:fied to represent the ownw,and <br /> 3. That bloke will assume fall respoaihility for ail tiabifily far pecsoaui injruy or damage to propedy whidm may arise out afthe wo&described above, <br /> or whichmay ansa out of Ns&w failure to do 9w work ptvdtde d herein;and <br /> 4. That in the event arty claim of auehliability is made against#*Coady of San]bag ort or any depaatmeot,offidd or employee there4 he shall <br /> deffead,indemnify and holdthenm and each of them harmless for such clam and <br /> S. That work shall be ped mmol by the applicant and/(r awry represedahYe of the applicant in the County Rigl W-Way at the above indicated site <br /> with a valid San Joaquin County E mcxoaemma t Permit;and <br /> 6. That if per»ssion is granted as ragwnted,he agrees to do the wads de cnW in acoomdaaoe with all teens,conditions and restricti0ml ofthis and any <br /> attached meet,included as geaeralor spacial III pmvrisioms. <br /> SigmsumeofRpplicad-Tine Date <br /> FIELD INSPECTOR CONK <br /> »»»»»»»»»»»»»»»»»»>>EMSIM40COMMON3««+c«««««««<c«««««««««< <br /> y <br /> L DRIVEWAY: None ❑ pint ;ff t3ravd ❑ Aggregate Base ❑ Pave xpoor) ❑ Pa-akOood) ❑ <br /> 2. SLOPING Away from Pavement ❑ Towards Pavomau -❑ Flat <br /> 3. PIMS:. Now Existing-Type <br /> Other pipes inneighbodwod: Yes ❑ No 0 Apprvadwe E Crass Dram ❑ Size <br /> Attachment to nei&bafs pipe: Yea ❑ No C& <br /> 4. HEADWAM Yes ❑ NO <br /> S, <br /> ASPHALT CONCRETE Yes ❑ No <br /> 6G.BARREMS a!*W 1 ght-a&Way <br /> 4. DTTCK Yes ❑ No �, IfYw:• V Style ❑ 2 Ma ❑ Other ❑ WW& Depth <br /> ?»»»»»»»»»»»»»»»»»»>PBRMITRBQCTZ1ZE1dENTS«««««««««««««««««««« <br /> 1.DRIVEWAY: OR GOMMMI. ❑ AGRtCE)I.Tuxt ❑ INDUSTRIAL ❑ <br /> PAVED with Z "Wm Depth A.0 over 4 "blm.DgAh 3/4"A.B. <br /> Notes <br /> 2. PIPE& Length of Pipe Regaim &' Fk mid Diameter of Pipe inch <br /> To be oceneded to arty amlyaoent driveway pipe Yea ❑.No <br /> DRAINAGE MM REQUIRED Yea No <br /> Total Languor. Tom Number of Sterm:Dry&Mdets <br /> Notes <br /> I BEADWALL Yes No <br /> 4. PAVED FRONTAGE: PAVED with "Mm.Depth AG over "Mm.Depth 3/4"A. <br /> Measuring Feeti n left&aad Fedin width <br /> FEES <br /> Driveway FacrOecdm>rot Permit base fico_....:...:._._._... ...585.00 <br /> FeldInepection <br /> awayw/orVV/o pipe........ _: _ _595.00 ❑Pavedau tags._....._....._ __....S100.00+0.46/S <br /> LJ Drivowayw/box Calvet._ _._ . „_..aiSi.00 ElCumtm,(Sutter,Sidewalk...:.. ...:...........5100.00+0.98M <br /> Carlen AMputer,c:VxceaslApp1iQdi0n for Permi4mdDriyeway and Paved Frontage Paga.2.cmf 2 Revised 8/2000. <br />