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THE APPLICANT HEREBY CE am that the description included infl&application are coated to the best of his/her <br /> 1. That he/she his read alt the provisions <br /> knowlwdgr and <br /> 2. That he/she is the owner of the respective Property,of is qual'dredto represmR the ownw;and <br /> 3. That ho/she will assuage fall regponsibRity <br /> for all tiabitity for personal.raVoryor damage to pr%m-ty w1nchmay arise out ofttm work described above, <br /> or which may arras out of his/her failure to do the wank pmvrded hereat;and official of Yce he shall <br /> 4. That in the event any claim of such liability is made againd%DComrtY of San YOagagn of nay , <br /> defend,indemnify and holdthem and each of them harmless for so&clmn;and <br /> Y aPP <br /> 5. That work shall be performed <br /> b the haul=&of say representative of the Wficant in the Courtly Rigbt. M&Y at the above indicated site <br /> with a valid San Joaquin CamtY E.ammchamit Pctmit;and <br /> 6. That if permission is granted as requested,he agrees to do the wady described in acoadmwe wrath all tangs,conditioms and restriction of this and any <br /> attached or III Pro' .21 & <br /> /0 <br /> 21 /O <br /> 7 <br /> Date <br /> 3igoa�e Title <br /> FIELD INSPECTOR Comau.NTS <br /> L DRi�EWAY: Nano [IDist � (travel ❑ Aggregate Base ❑ Pa ) ❑ Paved(Good) E] <br /> 2. SLOPING: A f vin Pavomgeot ❑ Towards Pavement10 <br /> F7af <br /> 3. PIPES: Nowa Egddiag-Type <br /> Other pipes is aeighborhgod: <br /> Yes ❑ No Approaches F-1Cross Drain El Stu <br /> )r. Yes ❑ No <br /> EA4. HDWALLL: Yea ElNo' <br /> S. ASPSALT CONCRETE DOM: Yes El No <br /> 6..BARRIERS along Rigid-ofDepth <br /> 1. DITCH Yes ❑ No IfYes: V style ❑ 2 pbint ❑ Dobai ❑ Width <br /> »»»»»»>»»»»»»>>>>> »PERMIT.g rQUHW «««««««««««««««««««« <br /> 1. DRIVEWAY: SFR 4 00MMERCI4L ❑ AGRiCULTURE ❑ INDUSTRIAL ❑ <br /> PAVED with "hfm Depth A.C.over �i"M•Depth 31V A.B. <br /> Notes <br /> 2. PIPE& Loa&$of Pipe Requi FL and Diameter of Piga Inch <br /> To be ooaneded to any adjacent driveway pipo YesNo — <br /> DRAINAOE INLET REQUIRED Yea ❑ No <br /> Taal I90011 (with proposed) Total Nmsber of Stmm Dra3u bdefa <br /> Notes <br /> 3. HEADWALL Yes ® No <br /> Al. PAVED FRONTAGE: PAVED with "Mm.Depth AC.over "Lf n.Depth 3/4"A.B. <br /> Measuring Feet in tem and Fed in width <br /> FEES <br /> Driveway Enaumboment Permit base fee............................585.00 <br /> reldInspection <br /> Pft.V:7.yyw/box <br /> w/or w/o ........._..S9S_OD ❑Pavedfrorrtaga-_......_......_........_....Sltpt>0+4.46/ft <br /> P _....._.._.._ .__. 5190.00+0.98/8 <br /> Cutverk._......__.......... . S15i.00 ❑Curb,Gutter,Sidewalk..:...... .......... <br /> CountalComputox,c:\AcceaeVpplieati <br /> on for Pumft\Driveway and Paved Frontage Page.2 of 2 Revised 8/2000 <br /> i <br />