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I. That hdsBehas read all the provisions <br /> ofthis and that the descr4don inchaded in this application are correct to the best of his/her <br /> leno,h,jgq and <br /> 2. Tbat hdshe is the owner of the respective proPedy,or is qualified to represent the owner,and <br /> 3. That hdshe will assume fall reapan�»'hl7i <br /> for all 'fwpetsomd i*"or damage to property wh i&may arise oat ef'the wait desaYbed above, <br /> or a h UY arise out ofws/her failureto do*a workpmvidad herein;and - oJTteisi of employee t ha shall <br /> 4. That is the event any claim of sachlia�y is made agaiest,h&Cwmty of San or any�, <br /> defend,indemnify and hold*=and each of them banmkas for such claim;and <br /> S. That wade shall be pedo mud by the applicant and/or anxy representative of&e Wficaot in the County Rigl*4--Way at the above indicated site <br /> vdth a valid San Joaquin CoudY Emsoadnment Pem%94 and and reatridion of this and any <br /> 6. That if permission is granted as requasted,he agrees to do the wade dwml)ed in scowlance widnall temm,oandWow <br /> enriched sheet,included as general ar slneeW III proviswm <br /> L•-- <br /> • Signstaue of�Qplicen!Tiib <br /> Date <br /> FIELD INSPECTOR COADdifM <br /> ExunwacomrrIONS«««««««««««««««««««« <br /> L DRIiVEWAY: None ❑ � ❑ t3iawel ❑ Anrog+ft Ban ElPaved(t+oor) ❑ Pave kGood) <br /> 2. SLOPING: Awayfrom Pavamed Towards Pavamnaot ❑ Flat ❑ <br /> 3. PIPES:. None Egg-Type <br /> Other Pipes inn6&borhood: Yes ❑ No Approdw 0 Cross Drain. ❑ Sin I i <br /> Madmoeat to neigwxes pipe: Yes ❑ No <br /> a HEADWAM, Yea ❑ No, <br /> S. ASPHALT CONCRETE DIItE: Yes ❑ No <br /> G.BARREERS aW8fR g"Way <br /> 1. MICS Yes ❑ No ® If yes:. V Style ❑ 2 Point ❑ Other ❑ W Depth <br /> <z««««««««««««««««««« <br /> »»»»»»»»»»»»»»»»»»»PER.MITRI+rQUIItEIsffi�1'TS , <br /> 1.DRIVEWAY:_ SFR ❑. DMUSIVIA <br /> COMMEWIAL AGRCMTM 0 ' <br /> PAVIiD with "Wm Dep'&A.C.over "ldm Dept 3/4"A R <br /> Notes <br /> of Pipe g,��' Int.and Diameter of Pipe inch <br /> 2. PIPES: - —" <br /> To be ocooeded to MY:,djaeeet+ki VMY Pipe Yes ❑.No <br /> DRAINAGE DaXT REQUIRED Yes ❑ No <br /> Toted Length (w1h proposW) Tota!Number of Stalm:DRIM bdeta <br /> Notes <br /> i HEADWALL Yes Q No <br /> +4 PAVED FRONTAICE: PAVED with "h m.Depth A.C.over <br /> "bfia Depth 3/4"AB. <br /> Mfg Fast in length and Peet in width <br /> - F]EES <br /> privewaY Facxnactmmt P base flee...................__$95.00 j/✓�E /HA TcCQ/i9[ ,tom`F �NG � 1f� <br /> Field Inspection <br /> ❑Ddvewayw/orw/opips._. __ _ _ _ __S93_UO ❑Pawxl <br /> ❑Driveway w/box Culvert.. SiS5.00 ❑Cndb,butter, --. .._ . $100.00+0.98/& <br /> t cuntawomOW.c:lAcoessWpplioation fur PecmitsWriyeway and Paved Frontage Page.2 of 2 Revised 8(2000 <br />