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1. That he/she has read all the provisions of ft apoicarM,amt that the deswipt, on kxWW,in ft ap , oQt0d-'b#je best-of <br /> hisibbr-knowledge,. xl <br /> 2. That he/she is the owner of the respective prop",or is qualified to tepesWthe owtor,ad" <br /> 3. That he/she will assume ftdl responsibility for all Rabi Ax persona; or pt �. arise apt cif <br /> describedabove,of�may arise out of hist fol&to do the work ;vid <br /> 4. That in the evert any daim of such liability ismade against the County of San�n.or a .. _.., <br /> thereof,he� ,ink and hold them ark'each of hat €Wssforsuch ; <br /> 5. That work shall be par=ed by'the applicant afar any representative of the applies th . <br /> indicatedsite with a S Oar Er�roatnerd Permi ;;and <br /> 6. Of That <br /> permission <br /> d ission is granted as requested,he agrees to do the work described in Wince <br /> included as geni*or special Iff provisions. <br /> .Z =_ <br /> S"xaature diee <br /> »»»»»>>»»»»»»»»»»»»»»»>FIELD IMSPEGTIQAI Gd1T ««c«rc«« « cc< «c«<cc<cccc <br /> EXtfG CONUMIjifS <br /> 1. DRIVEWAY: None <br /> �f Dirt ❑ Gravel. ❑ ANegate Base ❑ Paved(poor) ❑ Paved(good) ❑ <br /> 2. SLOPING Away from Pavement[ Towards Pavement ❑ Flat <br /> 3. PIPES: None Ur"' <br /> Existing—Type •' <br /> Other pipes inhborhood: Yes oes Class D Sipe <br /> 4. HEADWALL: Yes ❑ No <br /> 5. ASPHALT CONCRETEDWE: Yes ❑ No , <br /> 6. BARRIERS: along Right-of-Way t ' <br /> 7. DITCH: Yes Q No tf Yes: V Style ❑ 2 Point ❑ Other ❑ Width Depth <br /> »»»»»»»»»»>>»»»»»»»»»»»PERIMTS F QIJIi li i c«<c <4<cccc«<c«c«<c c< c< <br /> 1. DRIVEWAY: SFR L Commercial ❑ Agriculture 0 Industrial <br /> • �/ Un Depth A. . p <br /> Cover UP Depth�'<A.S.oa <br /> Paved with � <br /> F <br /> f <br /> 2. PIPES. Len of Pipe Required 1 <br /> I�ttl Ft and Diameter of Pipe � TA inch(es) <br /> To be connected to any adjacent driveway pipe Yes ❑ No <br /> Drainage Inlet Required Yes ❑ No <br /> Total Length: (with proposed) Total Number of Storm Drain Inlets: � <br /> Notes: <br /> i <br /> 3. HEADWALL: Yes ❑ No <br /> 4. PAVED FRONTAGE: Paved with '1" "Min Depth A.C.over °KoI3t%°A.B. <br /> Measuring Feet in length and feet in wft <br /> »»»»»»»»»»»»»»»»»»»»»>»»»>»»FEES««<<<<< t«cccc« c c<tc< «tc< cc< < < c<c « <br /> Driveway Encroachment Permit base fee $125.04' <br /> Field In ection <br /> Ddvowvay w/or w/o pipe $110.00 ❑ Paved Frontage $11e0'0+&5K <br /> Driveway w/box Culvert $179.00 Curb,Gutter,S7� $113,04+1: <br /> IMPMOV.ORGiSWESiCENTRALSERVICESIGER1CALtPUBSv.WKWL4STERP UACFIiBdTPffMDMVeMYDOC (101" page2af2 <br />