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1. t read4a ftp provisions of this apocation,and that the description included in this application are correct to the b, c of <br /> 2. le€si tyre restive ►,'or is tumid to represent the owner;and <br /> 3. - fug or persona;iayury or damage to property which may arise out of the work <br /> �ars <br /> descried e out of W gore to do the work provided herein;and <br /> 4, That th ft eventxy:t ,of�Crabikt�'is made against the County of San Joaquin or any department,official or employee <br /> thereof,# ;i rk ark hold stern and each of,them harmless for such claim;and <br /> 5. TIW voxkepi itte adlor arty representative of the application in the County Right-of-Way at the above <br /> may ° rattrtent Pem�and <br /> S; }lw . . twapes th do the work described in accordance with all terms,condition and restriction <br /> Of al .ItI provisions. <br /> c�flttTrtleDate <br /> »»»»»»»»> »»»»»»> >y»» >»>FjELD#r8P9CTI0K G JIENTS«««««««««««««««««««««< <br /> lel MONS <br /> 1. DRY tAY: *m,.W Dirt ❑ Gravel ❑ AWOgatO Base ❑ Paved(poor) ❑ Paved(good) ❑ <br /> . SLOPING: MwifiximPavWMA 13 TowardsPavement n Flat E31"" <br /> S. PIPES: Norte Emoting—Type <br /> tg, t Approaches Cross Drain Lj Size <br /> 4. HEADWALL: Yes ❑ into <br /> 5. ASPHALT CONCRETE D'RM: Yes ❑ No .. <br /> 6. BARRIERS: *tq ROW Way, Woad <br /> 7. DITCH: Yes ❑ No gYes: V Style ❑ 2 Point ❑ Other Q Width Depth <br /> >>>;*»»»»»»y»»»>?»»s»»»>»»»»»>pERWS'RE@UIREIMENTS««««««««««««««««««««« <br /> 1. DRIVEWAY: SFR Ro ,Commerdal ❑ Agriculture ❑ Industrial [� <br /> Pavedwith loo "Min Depth A.C.over _"Min Depth 3/4"A.B.over <br /> Notes: '+ -f' 1AVI • of A <br /> �7 <br /> 2 PIPES:. Lent of Ike Required Ft.and Diameter of Pipe inch(es) <br /> To be conned to any adjacent driveway pipe Yes [❑ No <br /> Drairtage IrgetRequired Yes ❑ No [ <br /> TOW Lem: (with proposed) Total Number of Storm Drain Inlets: <br /> Notes: <br /> 3. HEADWALL: Yes ❑ No [ <br /> 4. PAVED FRONTAGE: Paved with "Min Depth A.C.over "Min Depth 3/4 A.B. <br /> Measuring Feet in length acrd Feet in width <br /> »>»»y»»>»>>»»>>»»»»»»»»»»»»»»»>FEES««««««««««««««««««««««««««« <br /> Driveway EricroWment permit base fae $126!00 <br /> R <br /> DrNewayy wl or w/o pipe $110.00 a Paved Frontage $116.00+0.53/ft. <br /> Driveway w0box Culvert $179.00 Curb,Gutter,Sidewalk $113.00+1.08/ft. <br /> 1 py. $ AtW4J6 S1k 0AGt EW PEUT DRKWAUX (10/09) Page 2 of 2 <br /> wir"." <br />