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inn,tirrl�t�t1L�t rt n,iMD I t,Aic1 MMM <br /> 1. That he/she bas read all the provisions of this apgli�and that the description inchded Mi tbis application are to the best of his/her <br /> knowlwdge;and <br /> 2. That he/she is the owner of the respective property,or is qualified to represent the owner;and <br /> 3..That he(she will assume fall responsibility for all liability forperaor d injury or damage to property wbioh may arise out oftba work described above, <br /> or which may arise out of his/her failure to do the work provided herein;and <br /> 4. That in the event any claim of such habffy is made against*aCounty of San abac or any departmen,official or emplcyee lixtwt be shall <br /> defend,indenmify and hold*=and each of then WW=for suds claims and <br /> S. That work shall be performed by the applicant and/or any repmentatiVe ofthe applicant in the County Right-of-way at the above indicated site <br /> with a valid San Joaquin County Encroachment Perm and <br /> 6. That if percussion is granted as requested,he agrees to do the wok described in a000adance with all ten ns,oonddions and restriction ofthis and <br /> any <br /> attached sheet,included as general or special III provisions. <br /> Sign dmm ofAppficamt-Title Date <br /> FIELD INSPECTOR COBUdWM <br /> »»»»»»»»»»»»»»»»»»»»EXiSTMO CONDMONS««««««««««««««<«««««< <br /> r <br /> L DRIVEWAY: Nene Xnt [� Gravel ❑ AWMpleBase ❑ Pavedgmw) ❑ Paved(Good) ❑ <br /> 2. SLOPING: Awayfraom P-e-NA ❑ Towanda Psvam ent ❑ Flat <br /> 3. YVES: Now ja Exiting-Type <br /> Other pipes innei6*od nod: Yes ❑ No [9 Approad. Q Cross Drain ❑ Stu —J <br /> Attadrment to neigbbo's pipe: Yes ❑ No <br /> 4. HEADWALL: Yea ❑ No <br /> 5.AWNALT CONCRETED Yes ❑ No <br /> &.BARRI RS along RW-o&Way <br /> 7. DITCH Yes ❑ No � esIfY V style ❑ 2 Point ❑ Omar ❑ widh Depth <br /> »»»»»»»»»»»»»»»»»»»PERMTRF,QUREMENTS«««««««««««««««««««« <br /> 1_DRIVEWAY: SFR COMMERCIAL ❑ AGRICULTURE ❑ INDUSTRIAL ❑ <br /> PAVED win 2 "Mm.Depth A.C.over 4 "Mm Depen 3/4"A lK <br /> New _ <br /> 2. PIPE& L alb of Pipe Required: Ft.and Diounsw of Pipe Inch <br /> To be connected to any adjac at driveway pipe Yes ❑ No <br /> DRAINAGE INLET REQUIRED Yea ❑ No <br /> Total Length: proposes Trial Number of Stor=e Drain Inlets <br /> Notes <br /> 3. HEADWALL Yes ® No <br /> 4. PAVED FRONTAGE: PAVED vd& "Mm.Depth AC.ova "Mm.Depth 3/4"A.B. <br /> Mpg Feet in length and Feet in widh <br /> FEES <br /> Driveway Encroachment t Permit base free......................... 85. <br /> Field Inspection <br /> voway w/or w/o pipe......... ..... ._ _ S_00 <br /> ❑ +0.46/ft <br /> Drivewayw/boxCulvart._.. . _........_.. ._... ....__..S15S.U0 ❑curb,Outter,Sidewa&..:.. .........$100.00+0.98/R <br /> CounterlComputer,c--V=sslApplication for PacmWDdy way and Paved Frontage Paga.2 of 2 Revised 812000 <br /> i <br />